Dermatoscopy: Alternative uses in daily
Giuseppe Micali, MD,aFrancesco Lacarrubba, MD,aDoriana Massimino, MD,aand
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 magnified (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 magnification (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
Key words: dermatoscopy; ectoparasitoses; epiluminescence microscopy; hair disorders; nail diseases;
Dermatoscopy, also known as dermoscopy, epi-
luminescence microscopy, or surface microscopy, is
a noninvasive technique allowing rapid and magni-
fied in vivo observation of the skin with the visual-
ization of morphologic features often imperceptible
to the naked eye. It is performed with manual
devices which do not require any computer ‘‘assis-
tance’’ 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 mag-
nification ranging from 310 to 31000.1,2The 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
to an epiluminescence microscopy technique facili-
tated by the application of a liquid (oil, alcohol, or
involving polarized light instead of liquids, with com-
toscopy and VD have been demonstrated to be useful
in a wide variety of cutaneous disorders, including
ectoparasitic infestations, cutaneous/mucosal infec-
tions, hair and nail abnormalities, psoriasis, and other
dermatological as well as cosmetologic conditions.
Both dermatoscopy and VD represent promising
and useful diagnostic tools for scabies. Their effec-
tiveness has been confirmed by numerous stud-
ies.1,4-13In particular, the accuracy of VD has been
demonstrated to be comparable to that of scraping.11
Dermatoscopic examination of active lesions
shows, at low magnifications (up to 340), the
presence of a small dark brown triangular structure,
corresponding to the pigmented anterior part of the
From the Dermatology Clinic, University of Catania,aand 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: firstname.lastname@example.org.
Published online February 4, 2011.
ª 2010 by the American Academy of Dermatology, Inc.
hair diameter diversity
pigmented purpuric dermatoses
mite, located at the end of a subtle linear segment,
the burrow4,14; together, both structures resembled a
jet with contrail. At higher magnifications (3100 to
3600), VD allows more detailed identification; the
oval translucent body of the mite is clearly visible
(Fig 1). One can also visualize other anatomic
structures, such as the anterior and posterior legs
and rostrum. In most cases,
it is possible to detect the
mite moving inside the bur-
magnifications allow visuali-
zation of other diagnostic
features, such as eggs and
VD is an easy, noninva-
sive, and relatively rapid
technique, which allows the
inspection of the entire skin
surface, particularly with the
use of a zoom-system instru-
ment, which requires neither
nor the application of any
liquid. False-negative results
are not common and depend
on the lack of operator expe-
superficial secondary bacte-
rial infection. Moreover, the
use of VD, especially at high
been regarded as highly spe-
cific with no false-positive
accepted compared to scraping, especially in the
addition, VD is comfortable, not painful, and has a
requiring repeated tests to make a final diagnosis.
Finally, it may also be used both for the screening of
family members and post-therapeutic follow-up.10,11
to 340) has some limitations, as it does not always
allow, especially to non-experienced operators, a
clear differentiation between the ‘‘jet-shaped’’ struc-
frequently occur in scabies due to repeated scratch-
ing. Another deficit is that mite viability cannot be
assessed at these magnifications, so that post-
therapeutic monitoring cannot be performed.
Head and pubic lice
The diagnosis of pediculosis capitis (head lice)
the clinical identification of either adult lice
(Pediculus humanus and Phthirus pubis, respec-
tively) or of viable nits through close-up examina-
tion. Louse combs and the magnifying lens represent
additional diagnostic tools which increase the possi-
bility to identify live lice.15-18In pediculosis capitis,
dermatoscopy ensures a more detailed evaluation of
both mites and eggs, particu-
larly in the presence of post-
treatment residual eggs.19,20
cally shows the presence of
thenitsfixed tothehair shaft,
allowing a rapid differentia-
tion from empty nits, the lat-
ter appearing as translucent
structures with a plane and
fissured free ending14,20or
scales of different origin or
pseudo-nits (hair casts, de-
bris of hair spray or gel, or
subsequent remarkable ef-
dermatoscopy does not re-
quire hair pulling, so that a
large scalp area can be inves-
tigated with minimal discom-
fort to the patient. Finally, a
close and accurate VD exam-
phology and physiology of
the lice themselves, together
with proving the pediculoci-
dal activity of topical agents.21,22
The diagnostic effectiveness of dermatoscopy
Dermatoscopy can be of particular importance in
children, where eyelashes are the most common site
of infestation. Phthiriasis palpebrarum is often mis-
diagnosed as atopic dermatitis or allergic conjuncti-
vitis because of the semitransparent and deep
burrowing aspect of the parasite at the lid margins.23
In these cases, dermatoscopy can rapidly clarify any
doubt by revealing the presence of lice and/or nits.
Finally, VD examination may enhance patient
compliance to therapy for both head and crab lice,
showing the presence, persistence, or resolution of
the infestation on a VD monitor.17
The dermatoscopic aspect of tungiasis, an ecto-
parasitosis caused by the flea Tunga penetrans, has
been described as a brown to black ring with a
d Dermatoscopy and videodermatoscopy
are noninvasive techniques allowing
magnified in vivo skin observation,
which have 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 some
cosmetological conditions) beyond the
traditional indication for pigmented
lesions of the skin.
d Dermatoscopy and videodermatoscopy
may be useful for differential diagnosis,
prognostic evaluation, and monitoring
response to treatment.
d The aim of this article is to advance
knowledge about and update the
alternative uses of dermatoscopy and
videodermatoscopy by reviewing
existing papers and presenting our
J AM ACAD DERMATOL
1136 Micali et al
central pore, corresponding to pigmented chitin
surrounding the posterior portion of the parasite’s
exoskeleton.24Additional dermatoscopic features
include a ‘‘gray-blue blotch’’, representing either
the developing eggs within the abdomen of the
flea25or to the presence of hematin in the gastroin-
testinal tract of the parasite.26After sequential and
careful shaving of the epidermis and gently com-
pressing the edges of the wound, a jelly-like bag full
of ovoid eggs is seen.27,28A 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 parasite’s eggs.28-30
Some authors have recently proposed dermatos-
copy as a valuable tool in the diagnosis of cutaneous
several species of the genus Leishmania. Diffuse
erythema and vascular structures, including comma-
shaped vessels, linear or atypical vessels, and arbor-
izing telangiectasia, are the most common findings.
In addition, initial lesions may show yellow oval or
composed of follicular plugs produced by the
compression of the follicular openings. Advanced
stages typically display hyperkeratosis, vascular
abnormalities (hairpin and dotted vessels), and the
so-called ‘white starburst’elike pattern adjacent to
the peripheral hyperkeratosis surrounding the cen-
evaluations need to be performed.
Clinical diagnosis of molluscum contagiosum, a
common skin infection caused by a poxvirus, is in
dermatoscopic examination may be helpful.14,32-34
Molluscum contagiosum shows a characteristic pat-
tern (Fig 2), consisting of a central polylobular white
to yellow amorphous structure with a peripheral
crown of reddish, linear or branched vessels, which
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).
Table I. Common dermatoscopy devices (cost
range: 200-1000 euros)
Table II. Common videodermatoscopy devices
(cost range: 5000-26,000 euros)
Fotofinder (Germany) 320 to 370
330 to 3300
330 to 3150
DS Medica (Italy)
34 to 3100
310 to 3200
310 to 3300Videoderm Zovam Europe (Italy)
Fig 1. Scabies. VD shows roundish body of Sarcoptes
scabiei (circle) at one end of the burrow (3100).
J AM ACAD DERMATOL
VOLUME 64, NUMBER 6
Micali et al 1137
do not usually cross the center of the lesion (‘red
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.14Such 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.14,35,36Flat warts
are characterized by regularly distributed, tiny, red
dots on a light brown to yellow background.14
The dermatoscopic findings in genital warts have
been described as a mosaic pattern consisting of a
white reticular network surrounding central small
islands of unaffected mucosal skin.14However, on
VD examination (3100), these islands appear to be
constituted by dilated vessels that are more evident
in papillomatous lesions in which, moreover, multi-
ple 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 genita-
lia, respectively.37,38Dermatoscopically, vestibular
papillae present as multiple transparent and cylin-
drical projections, containing irregular vascular
structures, whose bases, however, remain sepa-
rate37; pearly penile papules appear as whitish
pink cobblestone or grape-like structures in a few
rows with central dotted or comma-like vessels in
Recent observations have suggested the useful-
ness 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.14,39Moreover, some milia-like cysts
and whitish reticular streaks have also been de-
sufficiently specific alone, while their combination
may result in increased sensitivity.14,39Further con-
firmation on a larger series is needed.
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
VD significantly 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.40-44HDD 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 find-
ings has been suggested.45VD also facilitates inves-
tigation of the predominance of single over multiple
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).
J AM ACAD DERMATOL
1138 Micali et al
(from 2 to 4) follicular hairs in AGA ostia compared
with normal subjects.42Additional features include
peripilar signs, such as brown haloes, at the follicular
ostium, due to a superficial perifollicular lympho-
cytic infiltrate in an early stage of the disease,46and
yellow dots, consisting of degenerated follicular
keratinocytes plugged with sebum material, which
cause a distension of the follicle.41
VD findings of alopecia areata include yellow
dots, a number of dystrophic hair shaft features,
along with hypopigmented vellus hairs shorter than
10 mm.41,47The evaluation of these findings is
important both for diagnostic purposes as well as
for posttreatment follow-up. Yellow dots are de-
scribed as yellow to yellow red, round or polycyclic
dots of different size and correspond to dilated
follicular openings.41,47Dystrophic hair shafts are
they can be described as exclamation-mark hair and
cadaverized hair (black dots) and indicate strong
disease activity.40,43,47,48Conversely, short hypopig-
mented 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
VD evaluation of scarring alopecia provides
additional information, although scalp biopsy is
required to reach a final diagnosis. In lichen plano-
pilaris, VD shows the reduction to total absence of
orifices, hyperkeratotic perifollicular scales, and
erythema. In addition, perifollicular arborizing ves-
sels, pigmented networks, and white pale or blue-
to focal decrease in melanin content, can also be
observed.41,49Similar findings have been described
in frontal fibrosing alopecia (Fig 5), a variant of
In discoid lupus erythematous scalp atrophy
appears as a diffuse whitish area, particularly in
dark-skinned patients. Arborizing and tortuous ves-
sels 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 in-
clude 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 capil-
lary 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
inflammation or traction.52
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
VD evaluation improves the diagnosis of tricho-
tillomania and is a useful tool in differentiating this
compulsive disorder from other forms of alopecia,
limiting the number of skin biopsies.41,55With 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
shaft clinically characterized by a diffuse alopecia
due to hair fragility.56,57With the use of VD, the hair
shaft typically shows small oval nodes of normal
thickness separated by irregular dystrophic constric-
tions.58To describe this particular dermatoscopic
finding, some authors have suggested the term
‘‘regularly bended ribbon sign’’.56In addition, the
Fig 5. Frontal fibrosing alopecia. VD of frontotemporal
hairline shows reduction of follicular units and presence of
hyperkeratotic perifollicular collarettes (350).
J AM ACAD DERMATOL
VOLUME 64, NUMBER 6
Micali et al1139
differentiate monilethrix from pseudomonilethrix
and other causes of hair loss.
observed as an occasional finding in normal scalp, in
associationwith otherhairabnormalities oraspart of
a more complex genetic syndrome (Menkes syn-
drome, Bjornstad syndrome).40Dermatoscopically,
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 fizzy and unruly hair, which
gradually tends to improve with age. By VD, hair
shafts appear triangular, with atypical longitudinal
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.59By 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
hair’s higher susceptibility to become fractured con-
sequent to their fragility.40
Trichorrhexis invaginata (bamboo hair) is a hair
shaft abnormality that is generally associated with
of multiple nodes along the hair’s length caused by
observation shows the presence of multiple ball-
shaped nodes along the hairs, which causes the hairs
to break off.58,60
Dermatoscopic examination has been recently
utilized in the study of some nonpigmented lesions
and diseases of the nails.61,62Dermatoscopy can
analyze the nail in various anatomic aspects, such as
nail plate, hyponychium, distaledgeof thenail plate,
proximal nailfold, nail bed, and matrix and generally
requires the use of immersion gel or oil.61,62The
evaluation of nailfold capillaroscopic abnormalities,
widely utilized in the diagnosis of collagen tissue
disorders (systemic sclerosis and dermatomyositis),
has previously been published63,64and will not be
discussed in this review.
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 defined with the use of dermatoscopy.62
Moreover, dermatoscopic observation (340 to 370
magnification) of the hyponychium displays dilated,
severity of the disease.65
In some cases dermatoscopy may assist physi-
cians in evaluating onychomychosis.61,66,67Nail in-
fections caused by fungi producing melanin show
homogeneous brownish pigmentation devoid of
melanin granules and longitudinal streaks.
In a case report of onychomatricoma, dermato-
scopic evaluation at the nail plate showed longitu-
dinal white lines, indicating channels containing the
Evaluation of microvascular alterations is relevant
to investigate the pathogenesis of as well as to
enhance the diagnosis of psoriasis.69Over the years,
the role of VD in the study of psoriatic lesions has
gained increasing importance because of the identi-
fication of a peculiar vascular pattern.70-72VD at low
magnifications (310 to 350) of the psoriatic micro-
circulation inlesionalskin provides aglobal vision of
the vascular configuration characterized by a dotted
pattern. Higher magnifications (3100 to 3400) are
able to visualize dilated, elongated, and convoluted
capillaries showinga typical
‘‘bushy’’ quality (Fig 6).69,70The vessel caliber at
this level has been observed to be larger (12-13 ?m)
than in normal skin (5-6 ?m).73,74In perilesional
skin, capillary loops assume an elongated disposi-
tion, with a ‘‘hairpin’’ aspect, parallel to the
Fig 6. Psoriasis. VD shows dilated, elongated and convo-
luted capillaries with typical ‘‘bushy’’ pattern (3100).
J AM ACAD DERMATOL
1140 Micali et al
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 pre-
sentations, such as in palmar and/or plantar psoria-
sis,77psoriatic balanitis,78and 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
Clear cell acanthoma
Dermatoscopy of clear cell acanthoma, a benign
epidermal tumor clinically characterized by a well-
circumscribed, pink reddish papule, shows at low
magnification (320 to 350) homogeneous, symmet-
rical, dotted vessels throughout the entire nodule,
arranged either in a net-like pattern or as pearls on a
line.80-83At higher magnification (3200), the dotted
vessels display a bush-like aspect.82Thus dermatos-
copy can be a useful diagnostic tool.
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.84With the use of derma-
toscopy, port-wine stains have been classified as
superficial or papillary (type 1), consisting of round-
ish, red structures, and deeper or reticular (type 2),
represented by prominent, red linear structures,
forming irregular networks in the horizontal subep-
idermal plexus.84,85Another possible finding in-
cludes a gray whitish veil, due to the deep dermal
distribution of the lesion.86,87Two more patterns
have been observed. One is characterized by streaks
background. The second is composed of a particular
structure consisting of a pale halo surrounding a
to be predictive of poor laser therapy response.87
Dermatoscopy allows a noninvasive evaluation of
the entire lesion, compared with incisional biopsy,
which provides histologic information only for a
Bowen’s disease displays atypical vascular structures,
with a preponderance of dotted/glomerular vessels,
In pigmented Bowen’s disease, small brown globules
in a patchy distribution, a gray-brown diffuse pig-
mentation, and a pigmented pseudonetwork repre-
Dermatoscopy has been considered to be of help in
preoperatory evaluation, in follow-up, and in moni-
toring the nonsurgical outcome of the disease, in
which the disappearance of vascular structures may
indicate adequate treatment.88
Dermatoscopic examination of pyogenic granu-
loma 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.93,94Additional 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 le-
sions showing similar clinical features, but lacking
such dermatoscopic findings.
Dermatoscopic evaluation of lichen planus pro-
vides 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.95-98Wickham striae appear as pearly
whitish structures, which secondarily develop thin
spikes (‘‘comb-like’’ projections) or arboriform ram-
ifications departing from the periphery. Long-
standing lesions display a decrease in Wickham
striae, gradually surrounded by pigmented struc-
evolution and postinflammatory hyperpigmentation
of lichen planus.96
Urticaria and urticarial vasculitis
Dermatoscopy has been proposed for the evalu-
ation and the differential diagnosis of common
urticaria and urticarial vasculitis, based on the rec-
ognition of vascular and purpuric features.99The
dermatoscopic observation of common urticaria re-
veals a red, reticular network of linear vessels,
occasionally associated with dotted vessels. In addi-
tion, nonvascular areas within vascular structures, as
a consequence of massive edema, may be de-
tected.100Unlike common urticaria, urticarial vascu-
litis 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
J AM ACAD DERMATOL
VOLUME 64, NUMBER 6
Micali et al1141
urticaria or urticarial vasculitis, although the pres-
ence of purpuric globules is regarded as highly
indicative of an underlying vasculitis.100Based on
this, dermatoscopy may be considered a first-line
screening tool for a noninvasive and low-cost diag-
nosis in daily practice.
VD has been used to assess qualitative and quan-
titative structural alterations of capillaries in facial
rosacea with a pattern distinct from that of facial
seborrheic dermatitis.101In particular, some VD fea-
tures indicating rosacea include dilated vessels,
prominent telangiectasia, and large polygonal vas-
cular net (Fig 7). No alterations have been found in
the nailfold region, suggesting that rosacea does not
affect microvasculature of the distal extremities.101
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.102-104Some investigators refer to the cen-
predictive.102Nevertheless,the ‘‘cumulus sign’’isnot
exclusive to sebaceous hyperplasia.103Occasionally,
the ostium of the gland is visible as a small crater or
umbilication in the center of these yellowish struc-
tures. In this case, the central umbilication with the
peripheral cumulus have been defined as a ‘‘bonbon
Pigmented purpuric dermatoses
The term ‘‘pigmented purpuric dermatoses’’
(PPD), which includes lichen aureus, Schamberg
disease, Majocchi’s disease, Gougerot and Blum
syndrome, and eczematid-like purpura of Doucas
and Kapetanakis, has overlapping clinical and histo-
pathologic features resulting from the extravasation
of hemosiderin within the papillary dermis from
ies.98,106,107At 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.107This pattern could be useful to
distinguish PPD from other diseases, such as angi-
oma serpiginosum and venous stasis dermatitis.
Dermatoscopy has been recently proposed to
improve the preoperative diagnostic accuracy of
Kaposi’s sarcoma.108Most lesions show a homoge-
neous 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 glob-
ules.109,110Some authors have demonstrated the
relative specificity of the ‘rainbow pattern’ compared
with the pale delicate pigmentation in differentiating
Kaposi’s sarcoma from other cutaneous vascular and
nonvascular tumors. This ‘rainbow pattern’ histolog-
ically corresponds to closely packed ‘back-to-back’
vascular networks.108Nevertheless, more experi-
ence is needed to confirm these preliminary results.
Dermatoscopic evaluation of porokeratosis re-
veals a well-defined, whitish yellow peripheral an-
nular structure, with a brownish pigmentation in the
inner side.111-113This structure, which has been
Fig 7. Rosacea. VD shows large polygonal net of
thickened vessels (3100). Inset: A detail at higher magni-
Fig 8. Actinic porokeratosis. VD shows presence of a
‘‘white track’’ (arrows) surrounding a central red whitish,
scar-like area (330).
J AM ACAD DERMATOL
1142 Micali et al
described as ‘‘the outlines of a volcanic crater as
surrounds a central whitish or red-whitish, scar-like
area,in whichscalesand dotted orlinearvessels may
be observed.111-113In some areas, a double ‘‘white
track’’ may be present (Fig 8).113
At dermatoscopic examination, xanthomas show
a uniform yellowish pigmentation with subtle ery-
thematous border; this pattern has been compared
with a setting sun.114-116Moreover, some linear
and/or branched vessels may be present. Specific
features include brownish globules and dots of
dermal hemosiderin in reticulohistiocytoma, periph-
eral pigmented network with basal hyperpigmenta-
vessels, corresponding to dilated capillaries, and
VD can be of value in a variety of cosmetologic
disorders. It may enhance the visualization of xero-
sis, through the identification of lifted keratinocyte
In pseudofolliculitis barbae, VD displays the
course of sharp-pointed ingrown hairs on individual
papules responsible for extrafollicular and trans-
to evaluate the efficacy of therapy and to enhance its
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
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