Dermatology Reports 2019; volume 11:7916

Dermoscopy is a new diagnostic One of the commonest complaints in der- tool in diagnosis of common matology clinics is the eruption of macular Correspondence: Khitam Al-Refu, Faculty of or patchy hypopigmented skin lesions. This Medicine, Mutah University, Jordan. hypopigmented macular disease: complaint may be very disturbing to the Tel.: 00962797401149. A descriptive study patient, especially for those with dark skin. E-mail: [email protected] - Some of important hypopigmented macular [email protected] diseases1 are vitiligo, pityriasis alba, extra- Khitam Al-Refu Key words: Dermoscopy; Diagnosis; genital lichen sclerosus, achromic pityriasis Faculty of Medicine, Mutah University, Hypopigmented macules; Vitiligo. versicolor, idiopathic guttate hypome- Jordan lanosis and nevus depigmentosus. Conflict of interest: the author declares no Generally, these disorders share the same potential conflict of interest. patient’s complaint which is characterized Abstract by the presence of hypo or depigmented Funding: none. patches or macules. In this study, the aim One of the most frequent complaints in was to provide an overview on the use of Received for publication: 26 October 2018. dermatology clinics is the eruption of dermoscopy in dermatology by analyzing Revision received: 28 November 2018. hypopigmented patchy skin lesions. The Accepted for publication: 29 November 2018. the dermoscopic features of some of impor- aim of the study was to investigate the util- tant hypopigmented macular diseases. New ity of dermoscopy in common hypopig- This work is licensed under a Creative studies have documented dermoscopic fea- mented macular diseases. Patients with the Commons Attribution-NonCommercial 4.0 tures in vitiligo.10-19 Very few reports docu- International License (CC BY-NC 4.0). followings diseases were examined by der- mented these changes in idiopathic guttate moscopy: vitiligo, pityriasis alba, nevus hypomelanosis20,21 nevus depigmentosus,22-24 ©Copyright K. Al-Refu, 2018 depigmentosus, achromic pityriasis versi- achromic pityriasis versicolor25 and extra- Licensee PAGEPress, Italy color, idiopathic guttate hypomelanosis, and Dermatology Reports 2019; 11:7916 genital lichen sclerosus.26-28 This study extragenital guttate lichen sclerosus. doi:10.4081/dr.2018.7916 investigated 108 patients presented at der- This study showed that these hypopig- only matology clinics during the last three years mented macular diseases might display spe- complaining of hypopigmented and depig- cific dermoscopic features. In vitiligo, the for other hypopigmented skin diseases as mented cutaneous lesions. This current mean dermoscopic features were the pres- the diagnosis was based on clinical back- ence of a diffuse white glow with perifollic- study contained a larger number ofuse cases, ground combined with Wood’s light exami- ular pigment, perilesional hyperpigmenta- aiming to describe the common and uncom- nation and potassium hydroxide (KOH) tion, leukotrichia and the pigmentary net- mon dermoscopic features for the hypopig- scrapping. All of the cases were underwent work. In idiopathic guttate hypomelanosis, mented macular disease; comparing the Wood’s light examination. This was a very findings with the previous reports and doc- the characteristic features were the presence crucial method to confirm the diagnosis of umenting the frequency of them. of multiple, shiny, scaly macules with well- some cases such as vitiligo and pityriasis and ill-defined edges borders that coalesced versicolor. All of the scaly macules and into polycyclic macules. For nevus depig- patches were examined with potassium mentosus, the mean features were hypopig- Materials and Methods hydroxide scrapping. This is a very impor- mented patches with irregular border with a A total of 108 patients were seen at the tant test to confirm the diagnosis of all sus- faint reticular network. For pityriasis alba, dermatology clinics (Mutah University pected cases of pityriasis versicolor. The the fairly ill-demarcated hypopigmented Medical Center) during January 2015 to gently scrapped skin scales were placed macules with fine scales were the mean fea- commercialOctober 2017 complaining of patchy or directly onto a microscope slide and are ture. In lichen sclerosus, there were white macular hypopigmented lesions. Detailed covered with 10% potassium hydroxide, structureless areas, perilesional erythema- and informed consent was taken from the and were left to stand until clear and gently tous halo, follicular plugging and white patients. The sample collection was not heated to speed up the action of KOH. A chrysalis like structures. Dermoscopy of consecutive, as the intention was to investi- dermoscopic examination of all cases was achromic pityriasis versicolorNon showed a gate the patients who were diagnosed with performed using a hand-held dermoscope fairly demarcated white area with fine specific hypopigmented skin diseases. The (Dermlite DL3, Gen, USA) application scales localized in the skin creases. following skin diseases were included in the (10× magnification) with both polarized research: vitiligo, pityriasis alba, nevus and non-polarized lights. iPhone camera depigmentosus, achromic pityriasis versi- was attached to capture images. The dates color, idiopathic guttate hypomelanosis, and and times of capturing photos were auto- Introduction extragenital guttate lichen sclerosus. All of matically stored. The dermoscopic exami- Over the last few years, dermoscopy the cases which were on treatment were nation was done for all cases looking for has been shown to be a helpful tool in the excluded from the study. This was of partic- specific diagnostic finding for each case. diagnosis of many general dermatological ular concern for the cases of vitiligo; the The dermoscopic examination was done disorders.1-7 In addition to its well-docu- patients were on no treatment for three blindly without referring to the clinical or mented value in the diagnosis of skin months prior investigations. A detailed his- histological information. The following tumors and pigmentary melanocytic tory was taken, and dermatological exami- parameters were taken into consideration lesions, dermoscopy is very helpful in nation was done. A histopathological exam- when applying dermoscopy in these dis- assisting the diagnosis of various general ination was done for all cases of idiopathic eases: i) presence of altered pigmentation dermatological disorders, including guttate hypomelanosis and lichen sclerosus within the patch or macule; ii) The edge of scalp/hair diseases,8 nail/ nail-fold abnor- et atrophicus to confirm the diagnosis of the the macules or patch; whether it is fairly malities,9 and inflammatory dermatoses.1 disease. The histology was not performed demarcated or ill-defined; iii) Presence of

[Dermatology Reports 2019; 11:7916] [page 1] Article the scales within the lesion or surrounding lesion (28% of lesions). Figure 1 demon- Nevus depigmentosus was one of the skin; iv) Presence of perifollicular pigmen- strates some of these dermoscopic features common differential diagnosis of vitiligo. tation; v) Presence of perilesional reticulat- in vitiligo patients. All of the presented cases in this research ed hyperpigmentation or telangiectasia; vi) Patients with idiopathic guttate were children. Eight cases presented with The color of the hair within the hypopig- hypomelanosis were 11 cases (7 males, four an asymptomatic light patches that had been mented lesions; vii) The morphology/ females). The Average age of the patients first noted in the neonatal period. The arrangement of vascular structures. was 55.3 years with a range of 35 years to patches had been stable in shape, texture, Regarding the pattern or the shape of mac- 80 years. On physical examination, there but increasing in size with age. The mean ules in dermoscopy, there were different were multiple circular hypopigmented mac- age of presentation was 3 years with a range patterns described included:10 trichrome ules of various sizes ranging from 1 to 3 (1.5-12 years). Physical examination for pattern, nebulous pattern, polka dot pattern mm in diameter. The skin was scaly and each patient revealed a single, well-defined, (several depigmented macules), comet tail- showed some features of sun-damage. hypopigmented patch, with a serrated bor- ing of the lesion, amoeboid pattern, and Average disease duration was 6 years. The der. The surrounding skin was normal. petaloid pattern. histopathological findings for skin biopsies Wood’s light examination of the patch from these lesions demonstrated basket- showed an off-white accentuation without wave hyperkeratosis, epidermal atrophy, fluorescence. On dermoscopy (Figure 2B), and flattened rete ridges, and reduction of the hypopigmented patch with an irregular Results melanin pigment and numbers of and serrated boarder was the prominent fea- melanocytes. Dermoscopic features (Figure ture. Some of patches showed faint reticular In this study, 108 patients with the fol- 2A) for these cases were nearly similar in network within them. The borders also lowings diseases were enrolled in the study: all cases and was characterized by the pres- showed pseudopods pattern protruding into vitiligo (48 cases), pityriasis alba (16 ence of multiple, shiny, porcelain-white the normal skin. Hairs within the patches cases), nevus depigmentosus (8 cases), macules with well- and ill-defined edges was of normal colors, and there was no achromic pityriasis versicolor (16 cases), borders. These macules may coalesce into peripheral hyperpigmentation. idiopathic guttate hypomelanosis (11 polycyclic macules. Hyperpigmented net- Sixteen patients with pityriasis alba cases), and extragenital guttate lichen scle- works may be seen within the lesions or sur- wereonly examined with dermoscopy. The mean rosus (9 cases). Out of 48 patients with rounding skin giving the appearance of the age of presentation was 8.2 years. The mean vitiligo included in the study, 25 were cloudy-sky pattern. The surrounding skin duration of the patches was 12 weeks, and females, and 23 were males. The duration of was scaly. The hair was pigmented with no no treatment was prescribed. KOH scraping the disease ranged from 8 months to 2 peri-follicular hyperpigmentation. In addi-usewas negative for all cases and similarly was years; with an average duration of 4 tion, as has been described in vitiligo, it was the Wood’s light examination. On dermo- months. The mean age of onset was 24 common to see the petaloid, amoeboid, and scopic examination (Figure 3A), the years. Among the patterns of vitiligo, 23 nebuloid and polka dot appearance in some hypopigmented macules were fairly ill- patients had vitiligo vulgaris, acral distribu- cases (even in the same patient and in the demarcated white area with fine scales that tion in 11 cases, a focal variant in 10 cases same dermoscopic view) as has been are commonly distributed within and out- and 4 had segmental distribution. The most described in Figure 2A. side the macules. The hair inside the patch- common site was extremities followed by trunk and face. All cases demonstrated bright white (depigmented) areas with Wood’s light illumination with bright blue- white fluorescence. The dermoscopic analy- sis was done for established, progressive, or commercial regimenting vitiligo. All of the cases showed different activity of the disease even within the same patient. Regarding the pattern of pigmentation dermoscopy,Non a dif- fuse white glow was seen in 78% of cases, perilesional hyperpigmentation was present in 30% of cases, perifollicular hyperpig- mentation was present in 75% of cases, interfollicular pigmentation was seen in 40% of cases, white villus and terminal hair in 70% of cases, the pigmentary network within the lesions in 23% of cases, lesional and perilesional telangiectasia were present in 8% of cases. All of the lesions were not scaly in this study. Regarding the pattern in A B dermoscopy, there were different patterns Figure 1. (A) Dermoscopic view for vitiligo show depigmented patch, perilesional hyper- seen in this study in order of frequency as pigmentation (blue arrows) and depigmented hair (leukotrichia) (red arrow). It is promi- follows: nebulous pattern (72% of lesions), nent in the same view that the lower margin of the depigmented patch with ill-defined amoeboid pattern (63% of lesions), margins that merge indistinctly into the surrounding (Nebulous pattern) (blue stars). (B) trichrome pattern (58% of lesions), petaloid Dermoscopic view for vitiligo show Polka dot appearance with several depigmented mac- pattern (51% of lesions), polka dot pattern ules within a hyperpigmented background. Few macules show perifollicular repigmenta- tion and leukotrichia as well. (46% of lesions) and comet tailing of the

[page 2] [Dermatology Reports 2019; 11:7916] Article es was of normal color. There is no sharp margin to differentiate the hypopigmented patch from the surrounding skin. These fea- tures were seen in all cases of pityriasis alba. In addition, 30 % of cases demonstrat- ed erythematous changes within and sur- rounding the macules and patches. All of 16 patients with pityriasis versi- color were 12 males and four females. Mean age was 23 years. They did not have treatment prior to presentation. The mean duration of disease was 9 weeks. All cases had the lesions on their necks and upper A B trunk. The patients were asymptomatic. The Figure 2. (A) Dermoscopy of a lesion of idiopathic guttate hypomelanosis shows multiple, diagnosis was confirmed based on clinical roundish, homogenous, white-porcelain macules, and two were well defined (amoeboid assessment, KOH scrapping, and Wood’s pattern) (red arrows) and with irregular cloudy whitish pattern (nebuloid) (blue arrow). light illumination. The characteristic der- Several white shades present within the field represents the scales. In addition, these whitish areas were surrounded by a patchy hyperpigmented network (cloudy- sky pat- moscopic feature (Figure 3B) in 85% of tern) (blue stars). (B) The hypopigmented patches of nevus depigmentosus with irregular cases was diffuse hypopigmented blotches border (serrated) and with a faint reticular network within the patch. (fairly defined) with fine scales that were commonly localized in the skin furrows. In addition, some of the cases (65%) demon- strate satellite lesions (nearby small round white globules). In 22% of cases, the hypopigmented blotches were ill-defined, only but with prominent white, scaly globules. None of the cases demonstrated perilesional hyperpigmentation or perifollicular hyper- pigmentation. The hair inside these macules use was of normal color but covered by scales in some cases. In this study, 9 cases with extragenital lichen sclerosus were examined with der- moscopy. Seven females with mean age 11 A B years, with a range 7-18 years. Two cases are males, of age 28 and 34 years. The mean Figure 3. (A) Dermoscopic feature for a child with pityriasis alba. The hypopigmented duration of the disease 1, 8 years (with a macules were fairly ill-demarcated white area with fine scales that are commonly distrib- range from 1,2 to 2,3 years). The presenta- uted within and outside the macules. The hair inside the patches was of normal color. tion of these cases was white macules over There is no sharp margin to differentiate the hypopigmented patch from the surrounding skin. (B) Dermoscopic view for achromic pityriasis versicolor showed a fairly demarcated the trunk and extremities. It started as ery- white area with fine scales that are commonly localized in the skin creases. thema, expanding gradually, and finally commercial turned out to be a white patch. Examination revealed a well-demarcated, mild atrophic porcelain-white macules. The diagnosis for this cases was confirmed by histopathology Discussion (Figure 4) which showed hyperkeratosis,Non epidermal atrophy, squamatization of the Hypomelanosis of the skin encompass- basal cell layer and homogenization and es a wide spectrum of congenital and hyalinosis of the upper dermis. acquired alterations in melanin pigmenta- The predominant dermoscopic feature tion. They pose a diagnostic challenge for of lichen sclerosus (Figure 5) was white- the clinician; many of these hypopigmented yellowish structureless areas and white skin lesions appear similar. Vitiligo is one chrysalis like structures. This whitish color of the most common forms of acquired is glowing white and surrounded by an ery- hypomelanosis of the skin which can be thematous halo (as delicate linear branching treated in a guideline-oriented manner. But it carries tremendous social implications as vessels with different lengths and calibers) social stigma, especially in Arab countries especially in active lesions. Fine whitish and one of these Jordan (this research has scales were prominent. Follicular plugging been done). The eruption of hypopigmented was seen in new lesions of lichen sclerosus Figure 4. Histopathology of a lesion of skin lesions is of particular concern espe- extragenital lichen sclerosus showed hyper- et atrophicus and was not started on treat- cially in darker skin patients. The common keratosis, epidermal atrophy, squamatiza- ment yet. Table 1 summarized all the previ- skin type in Arab countries is the type III tion of the basal cell layer and homogeniza- tion and hyalinization of the upper dermis. ous dermoscopic features in all examined and IV Fitzpatrick skin types. Therefore, hypopigmented macular diseases.

[Dermatology Reports 2019; 11:7916] [page 3] Article there is a need for standardized criteria to previous study. In addition, interfollicular with such depigmented macules. It is com- differentiate this disease from other pigmentation was seen in 40% of cases, monly seen in elderly patients and charac- hypopigmented macular diseases. The der- white villus and terminal hair in 70% of terized by hypopigmented macules. The moscopy may be a helpful as a non-invasive cases, the pigmentary network within the diagnosis of idiopathic guttate hypome- tool in assisting the differential diagnosis of lesions in 23% of cases and lesional and lanosis is usually simple and can be several hypopigmented macular lesions and perilesional telangiectasia were present in assessed clinically, but sometimes, especial- has the potential to improve the diagnostic 8% of cases. The presence of telangiectasia ly in atypical sites, the distinction from accuracy. may be related to the history of treatment of other macular hypopigmented dermatoses19 Vitiligo is an acquired, autoimmune dis- patients by topical steroids. This marginal especially vitiligo may be challenging. This order characterized by well-demarcated and perifollicular marginal and perifollicu- study reported the dermoscopic features of depigmented macules and patches with or lar hyperpigmentation, reticular pigmenta- 11 cases with idiopathic guttate hypome- without leukotrichia. Evolving new lesions tion and marginal reticular pigmentation lanosis. These cases were complaining of of vitiligo are difficult to be distinguished may be associated with stability and repig- the presence of multiple tiny white spots on clinically from other causes of hypopig- mentation of vitiligo.17 Since the progres- shins and forearms resembling teardrops. mentation and depigmentation. The dermo- sive lesions of vitiligo display perifollicular There are two reports prior to this study scopic examination can detect subtle pigmentation and stable/remitting lesions demonstrating dermoscopic features in this 18 changes which may be useful in the early display perifollicular depigmentation. disease.20,21 The first one showed four pat- diagnosis of vitiligo from other differential Regarding the pattern, there were different terns (amoeboid, feathery, petaloid and neb- diagnoses of vitiligo. Some workers have patterns seen in order of frequency as fol- uloid patterns). The other study showed the studied the utility of dermoscopy in the lows: nebulous pattern (72% of lesions), typical features as cloudy sky-like pattern diagnosis of vitiligo. A pattern of depigmen- amoeboid pattern (63% of lesions), (multiple small areas coalescing into poly- tation with residual reservoirs of perifollic- trichrome pattern (58% of lesions), petal- cyclic macules, with several white shades ular pigment have been noted, and this was loid pattern (51% of lesions), polka dot pat- and both well- and ill-defined edges, sur- signifying focally active or regimenting tern (46% of lesions) and comet tailing of rounded by a patchy hyperpigmented net- 15 vitiligo. This residual perifollicular pig- the lesion (28% of lesions). A similar pat- work) and the cloudy pattern (well or ill- 10 only mentation had been observed in (91.9%) of tern has been reported before. defined roundish homogeneous whitish patients with progressing vitiligo and areas surrounded by a patchy hyperpig- 16 (62.9%) of those with stable vitiligo, and mented network. This study which was this can be considered as characteristic for Conclusions done in 11 cases, were nearly similar to the vitiligo lesions as it was absent in the non- usefindings of the second study. Dermoscopic 16 In conclusion, this study confirmed the vitiligo depigmented skin. In this study, 48 features for these cases were nearly similar findings in previous studies; the glowing cases of vitiligo had been examined by der- in all cases which characterized by the pres- white color was characteristic for vitiligo. moscopy. A diffuse white glow was seen in ence of multiple, shiny, white macules with In addition, this perifollicular pigmentation 78% of cases, perilesional hyperpigmenta- well- and ill-defined edges borders. These was seen in all stable and progressive cases tion was present in 30% of cases, and peri- macules coalesce into polycyclic macules. of vitiligo. There was a different pattern for follicular hyperpigmentation was present in The surrounding skin was scaly. The hair the depigmented patch of vitiligo, and this 75% of cases. In this study, the dermoscopic was pigmented as the surrounding skin with may reflect the activity and the progression analysis was done for established, progres- no follicular hyperpigmentation. In addi- of the disease. sive, or regimenting vitiligo, and this may tion, it was common to see the petaloid, explain the difference in frequency from the Idiopathic guttate hypomelanosis is another disease characteristically presented amoeboid, and nebuloid in all cases. These dermoscopic features were observed in this commercial study may be useful to support the clinical diagnosis of idiopathic guttate hypome- lanosis, distinguishing it from other hypopigmented macular lesions. Non For nevus depigmentosus, 8 cases pre- sented with an asymptomatic light patch that had been first noted in the neonatal period. Generally, the diagnosis of these cases was clinical. The commonly used clinical criteria proposed by Coupe22 for nevus depigmentosus are as follows: leuko- derma present at birth or of an early onset; no alteration in the distribution of leukoder- ma throughout life; no alteration in texture or change of sensation; and absence of a hyperpigmented border. Nevus depigmen- A B tosus should be differentiated from vitiligo, as both showed off-white accentuation. In dermoscopy, depigmented patches appeared Figure 5. The dermoscopic features of new lichen sclerosus et atrophicus (A) and an old with irregular and serrated border. There LSE lesions (B). Dermoscopy showing white structureless areas (blue stars) and comedo- was a faint reticular network within the like openings (yellow arrows) with telangiectasia of different lengths and calibers (red arrows). hypopigmented patch. The borders also showed pseudopods pattern protruding into

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Non pigmentation of vascular structure structure vascular of pigmentation pigmentation of lesions of scales perifollicular telangiectasia and arrangement and scales of telangiectasia perifollicular lesions of pigmentation (16 cases) were fairly ill-demarcated to differentiate the commonly hyperpigmentation. erythematous changes within patches was of normal color. normal of was patches within changes erythematous hyperpigmentation. commonly the differentiate to cases) (16 ill-demarcated fairly were The borders also showed showed also borders The pattern pseudopods skin. normal the into protruding the surrounding skin. and outside the macules. macules and patches. and macules macules. the outside and skin. surrounding the The disease The nature of The edge The presence The presence of The presence of The color of hair of color The of presence The of presence The presence The edge The of nature The disease The in (65%). (65%). in small round white globules) scaly globules. in some cases. some in globules) globules. white scaly round small within the lesions or the same lesion. same or the lesions the within surrounding pattern). (cloudy-sky the surrounding and within distributed from patch hypopigmented area. white an of Presence calibers. and patch like hypopigmented the chrysalis White (as halo erythematous skin. surrounding the from structures. was seen in 78% of cases. demarcated in all lesions were non-scaly. hyperpigmentation telangiectasia terminal hair in 70% in hair terminal hyperpigmentation telangiectasia non-scaly. were lesions all in demarcated cases. of 78% in seen was Interfollicular pigmentation with perilesional was present in 75% of cases. of 75% in present was cases. of 8% in present were perilesional with pigmentation Interfollicular was seen in 40% of cases. hyperpigmentation in in hyperpigmentation cases. of 40% in seen was The pigmentary network 30% of cases. of 30% network pigmentary The within the lesions in in lesions the within 23% of cases. cases. of 23% delicate linear branching branching linear delicate different with vessels calibers) and lengths lesions. active in especially (16 cases) Satellite lesions (nearby prominent white, skin furrows. by scales scales by furrows. skin cases) (16 (nearby lesions white, Satellite prominent Versicolor in 85% of cases. were ill-defined, but with localized in the color, but covered but color, the in localized with but cases. of Versicolor 85% in ill-defined, were Pityriasis blotches (fairly defined) hypopigmented blotches that were commonly hyperpigmentation. macules was of normal normal of was macules commonly were that hyperpigmentation. blotches hypopigmented defined) (fairly blotches Pityriasis Vitiligo (48 cases) A diffuse white glow The edge was well All of the lesions A perifollicular Lesional and perilesional White villus and villus White perilesional and Lesional A perifollicular lesions the of All well was edge The glow cases) (48 white A Vitiligo diffuse Achromic Diffuse hypopigmented In 22% of cases the Presence of fine scales There was no peripheral No specific changes. The hair inside these these inside hair The changes. specific No peripheral no was There scales fine of Presence the cases of 22% In hypopigmented Diffuse Achromic Tablle 1. Dermoscopic features of hypopigmented Tablle macular disease. was hair The pigmented. changes. specific No perifollicular no was There skin macules these of surrounding The edges The shiny, multiple, of Guttate Presence Idiopathic hyperpigmentation. scaly. was well-defined either were macules. porcelain-white Hypomelanosis within even cases) (11 networks ill-defined or Hyperpigmented the inside hair The demonstrated cases of 30% peripheral no was There are that scales Fine macules margin sharp no is There hypopigmented The Alba Pityriasis patches the inside hair The telangiectasia of Presence peripheral no was There scales whitish Fine sharp no is There White-yellowishLichen Extragenital color. normal of was lengths different with hyperpigmentation. prominent. were differentiate to cases) (9 margin Sclerosus areas. structureless (8 cases) within them. feature. colors. feature. cases) (8 them. within Nevus Some of the patches showed Serrated border of the All of the lesions There was no peripheral No specific changes. Hairs within the within Hairs changes. specific No peripheral no was There lesions the of All theof border normal of was Serrated showed patches patches the of Some Nevus hyperpigmentation. non-scaly. were prominent the was patches network reticular faint Depigmentosus

[Dermatology Reports 2019; 11:7916] [page 5] Article the normal skin. Hair within the patches whitish scales were prominent. In addition Schwartz RA. Dermatoscopy: alterna- was of normal colors, and there was no to the presence of shiny, fibrotic, white tive uses in daily clinical practice. J Am peripheral hyperpigmentation. In addition, beams radiating from the center of the Acad Dermatol 2011;64:1135-46. there was a normal colored peri-lesional lesions toward the periphery, they are 7. Zalaudek I, Lallas A, Moscarella E, et skin. This feature was described before.23,24 described as white chrysalis like structures al. The dermatologist’s stethoscope-tra- Pityriasis alba is a common benign skin in previous reports.26,27 They are parallel or ditional and new applications of der- condition causing hypopigmented facial orthogonal or disordered linear streaks and moscopy. Dermatol Pract Concept patches in children. Parents and patients are usually seen in dermatofibroma, basal cell 2013;3:67-71. often concerned about the cosmetic appear- carcinoma, Spitz nevus and melanoma.28 8. Miteva M, Tosti A. Hair and scalp der- ance and the similarity to the lesions of Although the diagnosis of lichen sclerosus matoscopy. J Am Acad Dermatol vitiligo (from the community view). But is mainly clinically and by histopathology, 2012;67:1040-8. here, the patches tend to be ill-defined. In in early stages of the disease, both are 9. Lencastre A, Lamas A, Sa D, Tosti A. addition, Wood’s light has little effect on the uncharacteristic.29,30 It has been reported Onychoscopy. Clin Dermatol 2013;31: hypopigmentation of pityriasis alba. that histopathological changes were non- 587-93. Sixteen cases with pityriasis alba were specific in one-third of men with character- 10. Gandhi S, Shamanur M, Shashikiran examined with dermoscopy. One previous istic clinical signs of lichen sclerosus. This AR, et al. Study of clinico-epidemiolog- report investigated this disease by der- disease is a scarring disease, and prompt ical and dermoscopic patterns of vitiligo moscopy.25 On dermoscopic examination, diagnosis is mandatory. These dermoscopic in pediatric age group. Ind J Paediatr the hypopigmented macules were fairly ill- features were highly characteristic and not Dermatol 2017;18:292-8. demarcated white area with fine scales that demonstrated in other hypopigmented mac- 11. Alghamdi KM, Kumar A, Taïeb A, are commonly distributed within and out- ular lesions. Ezzedine K. Assessment methods for side the macules. The hair inside the patch- This study showed that these hypopig- the evaluation of vitiligo. J Eur Acad es was of normal color. There is no sharp mented macular diseases might display spe- Dermatol Venereol 2012;26:1463-71. margin to differentiate the hypopigmented cific and characteristic dermoscopic fea- 12. Sosa JJ, Currimbhoy SD, Ukoha U, et patch from the surrounded skin. These fea- tures. As described in this research, some of al.only Confetti-like depigmentation: A tures were seen in all cases of pityriasis the dermoscopic findings in these hypopig- potential sign of rapidly progressing alba. In addition, 30% of cases demonstrat- mented macular diseases were non-specific. vitiligo. J Am Acad Dermatol ed erythematous changes within and sur- So, these dermoscopic findings should 2015;73:272-5. rounding the macules and patches. always be interpreted within the overall 13. Benzekri L, Gauthier Y. Clinical mark- In this study, all of 16 patients with clinical context of the patient history, useinte- ers of vitiligo activity. J Am Acad pityriasis versicolor were examined by der- grated with information from the history Dermatol 2017;76:856-62. moscopy. The characteristic dermoscopic and the macroscopic examination.2,3 14. Thatte SS, Khopkar US. The utility of feature in 78% of cases was diffuse Dermoscopy may scores over routine dermoscopy in the diagnosis of evolv- hypopigmented blotches (fairly defined) histopathology in the diagnosis of some ing lesions of vitiligo. Ind J Der VL with fine scales that were commonly local- skin disease in which skin biopsy may be 2014;80:505-8. ized in the skin furrows. In addition, most of traumatic as in case of nevus depigmento- 15. Chuh AA, Zawar V. Demonstration of the cases (85%) demonstrate satellite sus and pityriasis alba. It’s an additive test residual perifollicular pigmentation in lesions (nearby small round white glob- to confirm the diagnosis of pityriasis versi- localized vitiligo-a reverse and novel ules). In 22% of cases, the hypopigmented color, lichen sclerosus et atrophicus and application of digital epiluminescence blotches were ill-defined, but with promi- idiopathic guttate hypomelanosis. dermoscopy. Comput Med Imaging nent white, scaly globules. Actually, this Graph 2004;28:213-7. dermoscopic feature of presence of scales commercial 16. Meng R, Zhao G, Cai RK, et al. that were localized in the skin furrows was References Application of polarized light der- characteristic to pityriasis versicolor and moscopy in the early diagnosis of vitili- was not seen in other diseases that have 1. Errichetti E, Stinco G. The practical go and its differential diagnosis from been studied here. Non usefulness of dermoscopy in general other depigmented diseases. Chin J Extra-genital lichen sclerosus et-atroph- dermatology. J Ital Dermatol Venereol Dermatol 2009;42:810-3. icus is a chronic inflammatory dermatosis 2015;150:533-46. 17. Chandrashekhar L. Dermoscopy: A tool of unknown etiology. The presentation of 2. Lallas A, Giacomel J, Argenziano G, et to assess stability in Vitiligo. In: these cases was with white macules over the al. Dermoscopy in general dermatol- Khopkar U, ed. Dermoscopy and tri- trunk and extremities. 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