10.5826/dpc.1301a7
Introduction: Poikiloderma of Civatte (PC) is a common, acquired, chronic, benign poikiloderma of the neck and face, most commonly affecting menopausal females. Until the day of writing, few have been published regarding dermoscopy of PC.
Objective: To describe the dermoscopic picture of PC, so as to provide a clinico-dermoscopic diagnosis and differential diagnosis for PC.
Methods: Twenty-eight patients with PC, aged 26-73 years, of whom 19 females (67.86%) were evaluated by detailed history, clinical examination, and dermoscopic examination with hand-held dermatoscope.&nbsp;
Results: The reticular pattern was observed in 15 cases (53.6%); the white dot in 10 (35.7%); the non-specific in 9 (32.1%); and the spaghetti and meatballs-like in 8 (28.6%). Regarding local dermoscopic features, flying seagull-like vessels were observed in 18 cases (64.3%); linear irregular vessels in 17 (60.7%); rhomboidal/polygonal vessels in 15 (53.6%); dotted/globular vessels in 10 (35.7%); white macules in 23 (82.1%); brown macules in 11 (39.3%); and whitish follicular plugs in 6 (21.4%).
Conclusions: The dermoscopic picture of PC is highly characteristic and corresponds well to both clinical and histological findings. Dermoscopy may assist clinical diagnosis, as well as the differentiation from other dermatoses of the neck and face, especially poikilodermas with guarded prognosis.
text/xml
2160-9381
2311
en
Rainer  Hofmann-Wellenhof
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
differential diagnosis
Diagnosis and differential diagnosis of Poikiloderma of Civatte: a Dermoscopy Cohort Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-01-14
2023-01-31
2023-02-27
e2023007
Dermatol Pract Concept
Introduction: Poikiloderma of Civatte (PC) is a common, acquired, chronic, benign poikiloderma of the neck and face, most commonly affecting menopausal females. Until the day of writing, few have been published regarding dermoscopy of PC.
Objective: To describe the dermoscopic picture of PC, so as to provide a clinico-dermoscopic diagnosis and differential diagnosis for PC.
Methods: Twenty-eight patients with PC, aged 26-73 years, of whom 19 females (67.86%) were evaluated by detailed history, clinical examination, and dermoscopic examination with hand-held dermatoscope.&nbsp;
Results: The reticular pattern was observed in 15 cases (53.6%); the white dot in 10 (35.7%); the non-specific in 9 (32.1%); and the spaghetti and meatballs-like in 8 (28.6%). Regarding local dermoscopic features, flying seagull-like vessels were observed in 18 cases (64.3%); linear irregular vessels in 17 (60.7%); rhomboidal/polygonal vessels in 15 (53.6%); dotted/globular vessels in 10 (35.7%); white macules in 23 (82.1%); brown macules in 11 (39.3%); and whitish follicular plugs in 6 (21.4%).
Conclusions: The dermoscopic picture of PC is highly characteristic and corresponds well to both clinical and histological findings. Dermoscopy may assist clinical diagnosis, as well as the differentiation from other dermatoses of the neck and face, especially poikilodermas with guarded prognosis.
Rainer  Hofmann-Wellenhof
2023/01/31
10.5826/dpc.1301a7
e2023007
Department of Dermatology, Medical University of Graz, Graz, Austria 
2160-9381
differential diagnosis
en
e2023007
Diagnosis and differential diagnosis of Poikiloderma of Civatte: a Dermoscopy Cohort Study
https://dpcj.org/index.php/dpc/article/download/2311/1929
Diagnosis and Differential Diagnosis of Poikiloderma
      of Civatte: A Dermoscopy Cohort Study
       Alexandros C. Katoulis1, Dimitrios Sgouros1, Evangelia Bozi1, Georgia Pappa1,
Sofia Theotokoglou1, Marie Pauline Konstantinou1, Alexandra Voudouri1, Maria Voudouri1,
            Melpomeni Theofili1, Korina Tzima1, Rainer Hofmann-Wellenhof2


1 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens, Medical School, “Attikon” General
  University Hospital, Athens, Greece
2 Department of Dermatology, Medical University of Graz, Graz, Austria



Key words: poikiloderma, dermoscopy, epidemiology, diagnosis, differential diagnosis
Citation: Katoulis AC, Sgouros D, Bozi E, et al. Diagnosis and differential diagnosis of Poikiloderma of Civatte: a Dermoscopy Cohort
Study. Dermatol Pract Concept. 2023;13(1):e202307. DOI: https://doi.org/10.5826/dpc.1301a7
Accepted: July 15, 2022; Published: January 2023
Copyright: ©2023 Katoulis et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding Author: Alexandros Katoulis, 2nd Dept. of Dermatology-Venereology, “Attikon” General University Hospital, 1 Rimini Str.,
Athens 12462, Greece. Tel: 0030 210 5832396 E-mail: alexanderkatoulis@yahoo.co.uk




  ABSTRACT             Introduction: Poikiloderma of Civatte (PC) is a common, acquired, chronic, benign poikiloderma
                       of the neck and face, most commonly affecting peri-menopausal females. At the time of writing, few
                       studies have been published regarding the dermoscopy of PC.
                       Objective: To describe the dermoscopic picture of PC, so as to provide a clinico dermoscopic ­diagnosis
                       and differential diagnosis for PC.
                       Methods: Twenty-eight patients with PC, aged 26-73 years, of whom 19 females (67.86%) were
                       evaluated by detailed history, clinical examination, and dermoscopic examination with hand-held
                       ­dermoscope.
                       Results: The reticular pattern was observed in 15 cases (53.6%); the white dot in 10 (35.7%); the
                       non-specific in 9 (32.1%); and the combination of linear and dotted vessels in 8 (28.6%). ­Regarding
                       local dermoscopic features, converging curved vessels were observed in 18 cases (64.3%); linear
                       ­­irregular vessels in 17 (60.7%); rhomboidal/polygonal vessels in 15 (53.6%); dotted/globular vessels
                       in 10 (35.7%); white macules in 23 (82.1%); brown macules in 11 (39.3%); and whitish follicular
                       plugs in 6 (21.4%).
                       Conclusions: The dermoscopic picture of PC is highly characteristic and corresponds well to both
                       ­clinical and histological findings. Dermoscopy may assist clinical diagnosis, as well as the d
                                                                                                                     ­ ifferentiation
                        from other dermatoses of the neck and face, especially poikilodermas with guarded prognosis.




Original Article | Dermatol Pract Concept. 2023;13(1):e202307                                                                           1
Introduction                                                     females, gynecological history and menstrual status; skin
                                                                 phototype according to Fitzpatrick’s classification; sun ex-
Poikiloderma of Civatte (PC) is a rather common benign der-      posure habits: occupational or recreational, and the level of
matosis of the neck and face, mainly affecting fair-skinned      exposure; use of sunscreens; use of fragrances or fragranced
individuals, especially postmenopausal females. It is char-      cosmetics, applied on the sides of the neck or the décolleté
acterized by a combination of a reticular pattern of linear      area of the chest; and history of PC.
telangiectasia, mottled hyperpigmentation and superficial at-       During clinical examination, the following clinical pa-
rophy [1,2]. Clinically, it involves symmetrically sun-exposed   rameters were recorded: location; distribution; clinical type;
areas of the face, the neck, and the V-shaped area of the        and presence of clinical manifestations of rosacea. The der-
chest, invariably sparing the anatomically shaded areas [1,2].   moscopic examination was performed by an experienced
Depending on the prevalent clinical feature, PC can be clas-     evaluator (A.C.K.). For the dermoscopic examination, a Der-
sified into erythemato-telangiectatic, pigmented, and mixed      mlite DL200Hybrid (3Gen, San Juan Capistrano CA, USA)
clinical types [2]. The etiopathogenesis of PC is incompletely   hand-held dermoscope was used. Examination employed
understood. Exposure to ultraviolet radiation, hormonal          polarized light and a 10-fold magnification either without
changes of menopause, contact sensitization to perfumes and      contact of the glass slide with the skin or with contact but
cosmetics, and normal ageing have been incriminated. The         without applying pressure on the skin (for better visualiza-
diagnosis is usually clinical and can be confirmed by histol-    tion of the vascular component). Photographic documenta-
ogy, which is characteristic, but not pathognomonic [3]. The     tion was made using an iPhone 8 camera. Photographs were
course is slowly progressive and irreversible, often causing     taken from seven preselected sites, the same for all patients,
significant cosmetic disfigurement.                              on the upper chest, the sides of the neck, and the peripheral
    Dermoscopy is an in vivo diagnostic technique that has       face in a symmetrical manner.
considerably increased our diagnostic skills. Its use has been      Firstly, we attempted to describe the local features, pig-
extended, apart from Dermato-oncology, in almost every           mented or vascular, that predominated on dermoscopic
disease in the context of General Dermatology [4-6]. At the      examination among our patients. The following structures
time of writing, very few studies have been published regard-    were assessed: (i) rhomboidal/polygonal vessels, (ii) linear
ing the dermoscopy of PC.                                        irregular vessels, (iii) dotted/globular vessels, (iv) brown
                                                                 macules, (v) white macules, (vi) follicular plugs. Secondly, we
                                                                 analyzed and described the global pattern.
Objectives
The aim of the present study was to describe the dermo-          Statistical Methods
scopic picture of PC. Furthermore, we sought to assist the       For continuous variables, the mean, standard deviation and
differentiation of PC from other dermatoses of the face and      range, or the median, 25th and 75th percentiles and range,
neck and most importantly from acquired poikilodermas            were used after testing for normal distribution. For categori-
with poor or guarded prognosis (poikiloderma vasculare           cal variables, the frequencies and percentages were used. The
atrophicans and poikiloderma associated with collagen vas-       Shapiro-Wilk test for normality was applied.
cular disease), thus reducing the need for biopsy and histo-        Chi-squared and Fischer's exact tests were used for the
logic verification [1,2].                                        comparison of categorical variables while unpaired t-tests
                                                                 and Mann-Whitney U tests were applied depending on the
                                                                 distributions of the continuous variables. All statistical anal-
Material and Methods
                                                                 yses were performed using Stata/IC version 15.
The study was conducted at the 2nd Department of Dermatol-
ogy and Venereology of the National and Kapodistrian Uni-
                                                                 Results
versity of Athens at “Attikon” General University Hospital in
Athens, Greece during a period of 18 months (January 2018        The demographics, etiologic factors and clinical character-
– June 2019). Patients with a clinical diagnosis of PC, visit-   istics of our patients are summarized in Table 1. In total,
ing the outpatient clinic of our department, were recruited      28 patients with PC were recruited. The median age was 55
after they had given their informed consent. The study was       years (range 26-73 years). There were 19 females (67.86%)
approved by the Ethics Committee of the Hospital.                aged 46-73 years (median age 54 years), and 9 males aged
    In all patients, a detailed history was obtained which       26-65 years (median age 59 years).
included: demographic characteristics; family history with          On clinical examination, the mixed type was the most
an emphasis on the presence of a similar condition in other      prominent (71.43%), followed by the erythemato-telangiec-
family members; medical history, including drug history; in      tatic type (21.43%) and the pigmented type (7.14%). The


2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e202307
 Table 1. Demographics, etiologic factors and clinical characteristics of the patients with PC (N=28).
 Demographics
 Gender                                Females                                           Males
                                       19 (67.86)                                        9 (32.14)
 Age                                   55 years                                          59 years
 Etiologic factors
 Phototype (Fitzpatrick’s              I                        II                       III                          IV
 classification)                       3 (10.71)                7 (25)                   14 (50)                      4 (14.29)
 Occupational sun exposure             3 (10.71)
 Recreational sun exposure             22 (78.57)
 Sunburn in childhood                  2 (7.14)
 Use of perfumes                       16 (57.14)
 Menopause                             13 (68.42)
 Positive family history               9 (32.14)
 Clinical characteristics
 Duration                              1-5 years                6-10 years               11-15 years                  16-20 years
                                       5 (17.86)                11 (39.29)               9 (32.14)                    3 (10.71)
 Location of the lesions               V-shaped area of chest:              Sides of the neck:            Peripheral face:
                                       27 (96.43)                           11 (39.29)                    8 (28.57)
 Clinical type                         Erythemato-telangiectatic:           Pigmented:                    Mixed:
                                       6 (21.43)                            2 (7.14)                      20 (71.43)
 Symptoms                              Burning:                             Flushing:                     Pruritus:
                                       8 (28.57)                            6 (21.42)                     5 (17.86)
 Comorbidities                         Rosacea                  Thyroid diseases         Arterial hypertension:       Systemic lupus
                                                                                                                      erythematosus:
                                       12 (42.8)                8 (28.57)                5 (17.85)                    4 (14.28)

Numbers in parenthesis represent percentages



most common localization was the V-shaped area of the                          Based on the presence of the aforementioned vessel types
chest. Less than one-third of the patients complained of ac-             and their architectural distribution, we described four patterns:
companying symptoms (burning, flushing and pruritus).
    The most commonly reported comorbid skin condition                   • Reticular (fishnet-like) pattern: areas with linear telangi-
was rosacea (mainly of the erythemato-telangiectatic type),                  ectasias that are interconnected forming an irregular red
observed in approximately half of the patients. Moreover,                    network that is reminiscent of a fishnet. This network
disorders of the thyroid gland were also common, involv-                     consists of thin red lines and quadrilateral or polygonal,
ing 28.57% of the patients. It is of interest that 4/28 cases                irregular openings.
(14.28%) had a history of systemic lupus erythematosus.                  • White dot (red-white polka dot) pattern: white roundish
    On dermoscopic examination, the local dermoscopic fea-                   macules, regularly distributed in areas of bright red ery-
tures were assessed. We observed linear irregular vessels in                 thema produced by a network of linear telangiectasias. It
17 cases (60.7%); rhomboidal/polygonal vessels in 15 cases                   is reminiscent of a red-white polka dot print.
(53.6%); dotted/globular vessels in 15 cases (53.6%); white              • Combination of linear and dotted vessels pattern: a combi-
macules in 23 cases (82.1%); brown macules in 11 cases                       nation of linear irregular vessels and dotted/globular vessels.
(39.3%); and whitish follicular plugs in 6 cases (21.4%). In                 This pattern was initially described in patients with PC by
18 cases (64.3%), we identified a distinctive type of vessels,               Errichetti and Stingo as “spaghetti and meatballs” pattern.7
the converging curved vessels, presenting as two curved red              • Non-specific pattern: areas of irregular linear telangiecta-
lines that meet at their neighboring end, giving the impres-                 sias that are irregularly distributed and do not correspond
sion of a flock of seagulls flying with their wings wide open                to any specific pattern.
(“flying-seagull-like” vessels). Examples of the local dermo-
scopic features observed among patients with PC are shown                      The dermoscopic global patterns are summarized in
in Figure 1.                                                             ­Table 2. The reticular pattern was observed in more than


Original Article | Dermatol Pract Concept. 2023;13(1):e202307                                                                             3
 Figure 1. “Local structures of poikiloderma of Civatte”. A) The rhomboidal/polygonal vessels, B) the converging curved vessels, C) the
­dotted/globular vessels, D) the linear irregular vessels, E) the white macules, F) the brown macules, and G) the follicular plugs.




                            Table 2. Dermoscopic features in patients with PC (N=28).
                                                                                                                      Number of
    Dermoscopic patterns/structures                                       Description                                patients n (%)
 Global pattern
 Reticular (fishnet-like)                       Areas with linear telangiectasias that are interconnected              15 (53.57)
                                                forming an irregular red network that is reminiscent
                                                of a fishnet. This network consists of thin red lines and
                                                quadrilateral or polygonal, irregular openings.

 White dot (red-white polka dot)                Areas of bright red erythema produced by a network of                  10 (35.71)
                                                linear telangiectasias, surrounding regularly distributed
                                                white roundish macules. It is reminiscent of a red-white
                                                polka dot print.


 Combination of linear and dotted vessels A combination of linear irregular vessels and dotted/                         4 (14.28)
 (spaghetti and meatballs-like7)          globular vessels.




 Non-specific                                   Areas of linear telangiectasias that are irregularly distributed        9 (32.14)
                                                and do not correspond to any specific pattern.
 Vascular structures
 Rhomboidal/polygonal                           Bright red, non-branching, linear telangiectatic vessels; tend         15 (53.57)
                                                to connect with surrounding vessels forming interconnected
                                                rhomboidal or polygonal vascular structures, thus
                                                resembling parts of fishnet with irregular holes.
 Linear irregular                               Bright red, non-branching, linear telangiectasias with                 17 (60.71)
                                                irregular form and distribution.
 Dotted/globular                                Bright red, irregularly distributed dots or globules.                  10 (35.71)



4                                                                          Original Article | Dermatol Pract Concept. 2023;13(1):e202307
                                                                                                                     Number of
    Dermoscopic patterns/structures                                       Description                               patients n (%)
 Converging curved vessels (Flying               Double curved short red lines that meet at their neighboring          18 (64.29)
 seagull-like)                                   end; usually appear in small clusters.




 Pigmented structures
 Brown macules                                   Light brown structureless macules, 2-3 mm in diameter, with           11 (39.29)
                                                 rather distinct but slightly irregular borders.
 Depigmented structures
 White macules                                   Whitish or skin-colored spots, suggesting that they                   23 (82.14)
                                                 correspond to the holes of the vascular network which is
                                                 formed by the linear telangiectasias, representing areas of
                                                 sparing.
 White keratotic follicular plugs                Follicular hyperkeratosis                                             6 (21.42)



                 Table 3. Dermoscopic differential diagnosis of poikiloderma of Civatte.11-23
                                                                                Dermoscopic findings
 Riehl’s Melanosis                                   • Gray dots/granules and pigmented pseudo-network, combined with
                                                       telangiectatic vessels;
                                                     • Less often flour-like scales, follicular keratotic plugs and perifollicular
                                                       whitish halo.
 Erythromelanosis follicularis faciei et colli       • Round whitish areas with follicular plugs, occasionally centered by a
                                                       hair;
                                                     • Surrounding blue-gray dots or peppering in a reddish-brown
                                                       background
 Poikiloderma in dermatomyositis                     • Enlarged linear irregular vessels;
                                                     • Mixed features of hyperpigmentation and depigmentation.
 Poikilodermatous mycosis fungoides                  • Multiple polygonal structures consisting of lobules of white storiform
                                                       streaks, studded with fine red dots or hairpin vessels;
                                                     • Unevenly and intermittently distributed septa of pigmented dots,
                                                       between the lobules;
                                                     • Red and yellowish smudges.
 Poikiloderma atrophicans et vasculare               • Blurred branched vessels on a reddish or orangish-brown background;
                                                     • Sparse whitish scales.
 Chronic Graft-versus-                               • Whitish scales;
 host disease                                        • Vessels of mixed morphology, mostly dotted and linear
 Melasma                                             • Light-to-dark brown background;
                                                     • Brown granules/ globules with perifollicular sparing;
                                                     • Global reticular or pseudo-reticular pattern.



half of the patients, followed by the white dot pattern, and              In our statistical analysis, we investigated possible cor-
the non-specific pattern, while the combination of linear and         relations of the dermoscopic features and patterns with
dotted vessels pattern was the least frequently identified. In        epidemiologic parameters, etiologic factors and clinical char-
78.57% of the cases, the coexistence of more than one pat-            acteristics of our PC patients (Table 4). The following sta-
tern at different sites was noted. When the global pattern            tistical correlations were documented: white macules were
was assessed by anatomic region, i.e. face, neck, and upper           correlated with the mixed clinical type (p=0.015); converg-
chest, no significant differences were observed. Examples of          ing curved vessels were correlated with the erythemato-tel-
the dermoscopic global patterns observed among our pa-                angiectatic type (p=0.028); brown macules were associated
tients are shown in Figure 2.                                         with skin phototype IV (p=0.016) and with disease duration



Original Article | Dermatol Pract Concept. 2023;13(1):e202307                                                                        5
Figure 2. “Global patterns of poikiloderma of Civatte”. A) The fishnet-like pattern, B) the red-white polka dot pattern, C) the combination
of linear & dotted vessels pattern, and D) the non-specific pattern.




    Table 4. Distribution of local dermoscopic features by clinical type among patients (N=28) with
                                       poikiloderma of Civatte.
                                                                                  No of patients (%)
                 Type of PC
                Dermoscopic                            Erythemato-telangiectatic                  Pigmented             Mixed type
                  Features                                    type (N=6)                          type (N=2)              (N=20)
 Rhomboidal/polygonal vessels                                     2 (33.33)                             0                  13 (65)
 Dotted/globular vessels                                          4 (66.66)                          1 (50)                11 (55)
 Linear irregular vessels                                          3 (50)                            2 (100)               13 (65)
 Converging curved vessels                                         6 (100)                           1 (50)                12 (60)
 White macules                                                     3 (50)                            1 (50)                19 (95)
 Brown macules                                                    1 (16.67)                          2 (100)                9 (45)



6                                                                             Original Article | Dermatol Pract Concept. 2023;13(1):e202307
>5 years (p=0.009). Nevertheless, the number of cases in our         (converging curved vessels, rhomboidal/polygonal vessels,
study was relatively small to allow the extrapolation of solid       linear irregular vessels, dotted/globular vessels) that we iden-
conclusions.                                                         tified are the dermoscopic correlates of linear telangiectasia
                                                                     of poikiloderma and represent the dilated hyperemic vessels

Conclusions                                                          of the papillary dermis that have been described in the histo-
                                                                     pathology of PC.3 When the course of the vessels is parallel to
As our results indicate, PC exhibits a rather characteristic         the skin surface, they appear on dermoscopy as rhomboidal/
dermoscopic picture. The dermoscopic findings in PC con-             polygonal or linear irregular vessels, while when their course
sist of vascular and pigmented local features, forming a             is perpendicular they appear as dotted/globular vessels. The
reddish-to-brownish network. We were able to describe four           mottled hyperpigmentation of poikiloderma is dermoscop-
distinct global patterns (reticular, white dot, combination          ically appreciated as brown macules, and results from the
of linear and dotted vessels, and non-specific). The reticu-         increased presence of melanin irregularly distributed in the
lar pattern was the most frequently identified (53.57%). In          basal layer of the epidermis, as well as the presence of mela-
the majority of patients, the coexistence of more than one           nophages laden with melanin in the dermis [3]. In our se-
pattern was noted. We were able to describe four types of            ries, brown macules correlated with the mixed type of PC
telangiectatic vessels (converging curved, rhomboidal/po-            (p=0.015). White macules correspond to the superficial atro-
lygonal, dotted/globular, and linear irregular). Converging          phy that integrates the clinical triad of poikiloderma. White
curved vessels have not been described previously in any skin        macules correlate histologically to a flattened and atrophic
condition and could be considered highly characteristic of           epidermis, overlying an elastotic papillary dermis at sites in
the erythemato-telangiectatic type of PC (p=0.028). White            between the reticulate telangiectasia [3].
macules were seen in the vast majority of our patients and in           PC presents with a distinctive dermoscopic picture. By
all clinical types, either regularly (white dot pattern) or irreg-   dermoscopy, PC can be easily differentiated from other skin
ularly (reticular or non-specific pattern) distributed and in a      conditions characterized also by telangiectasia and reticular
follicular or pseudo-follicular distribution. Brown macules          pigmentation, such as rosacea, erythromelanosis follicularis
were observed much less often, mostly associated with the            faciei et colli and melasma, or true poikiloderma. Rosacea
pigmented and the mixed clinical type.                               which often coexists with PC most commonly involves the
    In the literature, there is little published experience on       central face. In rosacea, linear telangiectatic vessels arranged
the dermoscopy of PC. Errichetti and Stinco studied 8 con-           in horizontal and vertical lines form polygons (polygonal
secutive cases (6 women and 2 men, aged 42–73 years, mean            vessels) [5, 8, 9]. Vascular polygons are a characteristic der-
51 years) of clinically diagnosed PC.7 The authors described,        moscopical feature of erythemato-telangiectatic rosacea [6].
in all patients, a combination of dotted/globular vessels and        The vascular polygons are similar to the polygonal vessels
linear irregular vessels, giving the impression of “spaghetti        observed in half of our patients with PC, providing further
and meatballs”, along with perifollicular whitish (spared)           support to the theory that rosacea and PC are related and,
areas. In addition, they noted the presence of follicular ker-       possibly, belong to the same nosological spectrum [10]. In
atotic plugs and delicate reticular or structureless brownish        rosacea, additional features such as rosettes, white/yellow-
areas in 25% and 12.5% of the cases, respectively.7 Our              ish scales, orange-yellowish areas, pigmentation structures,
findings are in line with the findings of Errichetti and Stinco.     dilated follicles and follicular pustules (in the papulopustu-
However, the combination of linear and dotted vessels pat-           lar form), have been described that were not present in our
tern was not recognized by us as the predominant global pat-         cohort allowing differentiation between these entities [5, 8,
tern, but it was seen in as much as 28.6% of our patients.           9]. The dermoscopic differential diagnosis of PC is depicted
The presence of dotted/globular vessels was less common in           in Table 3.
our cohort as well. Accordingly, for the white macules, we              Our study has several limitations. Due to the small num-
noticed that they often have a pseudo-follicular distribution,       ber of patients, our results need further confirmation in
i.e. they are not strictly related to the follicular openings. In    larger prospective cohorts. Additionally, due to the lack of a
our cohort, brown macules were mainly associated with skin           control group, the sensitivity and specificity of the proposed
phototype IV (p=0.016) and with a disease duration >5 years          criteria were not calculated.
(p=0.009). Brown macules were mostly identified in the pig-             To our knowledge, this is the first study to systematically
mented and mixed clinical types of PC.                               investigate the dermoscopic characteristics of PC. Although
    The dermoscopic findings correlate well with both the            not pathognomonic, the dermoscopic picture is highly char-
clinical and histologic features of PC, supporting the view          acteristic, leading to the clinical diagnosis with great confi-
that dermoscopy represents a bridge between clinical pre-            dence. We were able to describe patterns and features that
sentation and histology. The vascular dermoscopic structures         are unique for PC, permitting the differentiation from other



Original Article | Dermatol Pract Concept. 2023;13(1):e202307                                                                      7
dermatoses of the face and neck, as well as from other forms              10. Katoulis AC, Georgala S, Stavrianeas NG. Poikiloderma of Ci-
of poikiloderma with guarded or serious prognosis. Dermo-                       vatte and rosacea: Variants in the same nosological spectrum.
                                                                                Dermatology 2005; 211:386-387.
scopic findings correlate well with the clinical and histo-
                                                                          11.   Wang L, Xu AE. Four views of Riehl’s melanosis: clinical ap-
logical features of PC. On this basis, biopsy and histologic
                                                                                pearance, dermoscopy, confocal microscopy and histopathology.
examination are rarely necessary. Future research will, hope-                   J Eur Acad Dermatol 2014; 28:1199-1206.
fully, better clarify the pathogenetic mechanisms of this dis-            12.   Maouni S, El Anzi O, Sqalli A, et al. Erythromelanosis follicularis
ease and will provide insights for more effective preventive                    faciei et colli: dermoscopy and dermatopathology correlates.
and therapeutic approaches for PC.                                              JAAD Case Rep 2019; 5:535-536.
                                                                          13.   Sonthalia S, Jha AK, Langar S. Dermoscopy of melasma. Indian
                                                                                Dermatol Online J 2017; 8:525-526.
                                                                          14.   Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiologic
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8                                                                                Original Article | Dermatol Pract Concept. 2023;13(1):e202307
