10.5826/dpc.1304a284
Introduction: The diagnosis of mycosis fungoides (MF) is challenging since it can mimic a variety of benign skin conditions. Multiple biopsies for histopathologic and immunohistochemical examination are required to diagnose MF. Dermoscopy is an affordable, non-invasive device with expanding indi-cations in dermatology,
Objectives: To investigate the dermoscopic morphology of MF variants and assess the correlation between dermoscopic criteria, histopathologic, and immunohistochemical findings,
Methods: We included 88 patients with several MF variants (classic, hypopigmented, hyperpigment-ed, poikilodermatous, erythrodermic, and folliculotropic).The diagnosis was histopathologically and immunohistochemically confirmed. Dermoscopic findings were collected, statistically analyzed, and correlated with the results of histopathology and immunohistochemistry,
Results: All patients had MF diagnosis in H&amp;E-stained sections.The majority revealed positive stain-ing with CD3, 4, 8 and negative CD7. Orange-red areas of discoloration, short linear, and spermato-zoa like blood vessels are the most frequent dermoscopic findings, while an analysis per MF variant was also performed.The frequently observed dermoscopic structures in classic MF were patchy whit-ish scales, dotted, short linear vessels, and spermatozoa-like vessels,
Conclusions: Dermoscopy reveals a repetitive dermoscopic pattern in MF (non-homogenous pink to erythematous background, patchy areas of orange discoloration, patchy whitish scales, dotted and short linear blood vessels with some variations according to the clinical variant.
text/xml
2160-9381
3408
en
Aimilios  Lallas 
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
 immunohistochemistry
Dermoscopy in the Diagnosis of Mycosis Fungoides: Can it Help?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-04-11
2023-10-31
2024-01-16
e2023284
Dermatol Pract Concept
Introduction: The diagnosis of mycosis fungoides (MF) is challenging since it can mimic a variety of benign skin conditions. Multiple biopsies for histopathologic and immunohistochemical examination are required to diagnose MF. Dermoscopy is an affordable, non-invasive device with expanding indi-cations in dermatology,
Objectives: To investigate the dermoscopic morphology of MF variants and assess the correlation between dermoscopic criteria, histopathologic, and immunohistochemical findings,
Methods: We included 88 patients with several MF variants (classic, hypopigmented, hyperpigment-ed, poikilodermatous, erythrodermic, and folliculotropic).The diagnosis was histopathologically and immunohistochemically confirmed. Dermoscopic findings were collected, statistically analyzed, and correlated with the results of histopathology and immunohistochemistry,
Results: All patients had MF diagnosis in H&amp;E-stained sections.The majority revealed positive stain-ing with CD3, 4, 8 and negative CD7. Orange-red areas of discoloration, short linear, and spermato-zoa like blood vessels are the most frequent dermoscopic findings, while an analysis per MF variant was also performed.The frequently observed dermoscopic structures in classic MF were patchy whit-ish scales, dotted, short linear vessels, and spermatozoa-like vessels,
Conclusions: Dermoscopy reveals a repetitive dermoscopic pattern in MF (non-homogenous pink to erythematous background, patchy areas of orange discoloration, patchy whitish scales, dotted and short linear blood vessels with some variations according to the clinical variant.
Aimilios  Lallas 
2023/10/31
10.5826/dpc.1304a284
e2023284
First Department of Dermatology, Aristotle University, Thessaloniki, Greece
2160-9381
 immunohistochemistry
en
e2023284
Bosseila M, Sayed Sayed K, El-Din Sayed SS, Abd El Monaem NA. Evaluation of Angiogenesis in Early Mycosis Fungoides Patients: Dermoscopic and Immunohistochemical Study. Dermatology. 2015;231(1):82-86. DOI: 10.1159/000382124. PMID: 26044542.
Dermoscopy in the Diagnosis of Mycosis Fungoides: Can it Help?
https://dpcj.org/index.php/dpc/article/download/3408/2391
Dermoscopy in the Diagnosis of Mycosis Fungoides:
                  Can it Help?
       Sarah Hamdy Soliman1, Wafaa Mohammad Ramadan1, Amal Ahmed Elashmawy 1,
                              Sameh Sarsik1, Aimilios Lallas2


1 Dermatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
2 First Department of Dermatology, Aristotle University, Thessaloniki, Greece



Key words: mycosis fungoides, diagnosis, dermoscopy, histopathology, immunohistochemistry
Citation: Soliman SH, Ramadan WM, Elashmawy AA, Sarsik S, Lallas A. Dermoscopy in the Diagnosis of Mycosis Fungoides: Can it Help?
Dermatol Pract Concept. 2023;13(4):e2023284. DOI: https://doi.org/10.5826/dpc.1304a284
Accepted: June 10, 2023; Published: October 2023
Copyright: ©2023 Soliman 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: Sarah Hamdy Soliman, MSc, Dermatology Department, Faculty of Medicine, Tanta University, Tanta, 31527,
Egypt. E-mail: sara.hamdy@med.tanta.edu.eg




  ABSTRACT             Introduction: The diagnosis of mycosis fungoides (MF) is challenging since it can mimic a variety of
                       benign skin conditions. Multiple biopsies for histopathologic and immunohistochemical examination
                       are required to diagnose MF. Dermoscopy is an affordable, non-invasive device with expanding indi-
                       cations in dermatology,
                       Objectives: To investigate the dermoscopic morphology of MF variants and assess the correlation
                       between dermoscopic criteria, histopathologic, and immunohistochemical findings,
                       Methods: We included 88 patients with several MF variants (classic, hypopigmented, hyperpigment-
                       ed, poikilodermatous, erythrodermic, and folliculotropic). The diagnosis was histopathologically and
                       immunohistochemically confirmed. Dermoscopic findings were collected, statistically analyzed, and
                       correlated with the results of histopathology and immunohistochemistry,
                       Results: All patients had MF diagnosis in H&E-stained sections. The majority revealed positive stain-
                       ing with CD3, 4, 8 and negative CD7. Orange-red areas of discoloration, short linear, and spermato-
                       zoa like blood vessels are the most frequent dermoscopic findings, while an analysis per MF variant
                       was also performed. The frequently observed dermoscopic structures in classic MF were patchy whit-
                       ish scales, dotted, short linear vessels, and spermatozoa-like vessels,
                       Conclusions: Dermoscopy reveals a repetitive dermoscopic pattern in MF (non-homogenous pink to
                       erythematous background, patchy areas of orange discoloration, patchy whitish scales, dotted and
                       short linear blood vessels with some variations according to the clinical variant.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023284                                                                      1
Introduction                                                         basis for diagnosis of the studied cases: atypical lympho-
                                                                     cytes, epidermotropism with Pautrier microabscesses,
Cutaneous T-cell lymphoma is the most frequent extra-nodal           some atypical lymphocytes exhibited arrangement along
non-Hodgkin lymphoma. It comprises a wide variety of                 the epidermal side of the dermo-epidermal junction
types, the most frequent being mycosis fungoides (MF) and            and atypical dermal infiltrate with a variable density as
Sezary syndrome (SS) [1]. MF is characterized by a significant       proposed by Smoller et al [7]. ­Immunohistochemically
variability of clinical manifestations. Classically, it evolves      stained tissues using CD3,4,8, and 7 were performed
in 4 sequential stages (patch, plaque, tumor, and erythro-           and assessed according to the percentage of stained
dermic), but several less frequent clinical variants do exist        cells considering the positive stain if the percentage ≥
(eg hypopigmented, poikilodermatous) [2]. The ­diagnosis of          30% whereas percent ≤ 30% is considered negative [8].
MF is very often challenging and necessitates the integration        CD3 positive staining with positive CD4 or CD8, and
of information acquired by clinical histopathologic and im-          negative staining for CD7 were the immunohistochemi-
munohistochemical assessment [1].                                    cal features of most of the included cases.
    In addition to its usefulness in the assessment of pig-       2. The presence of clinical manifestations (even mild) at
mented cutaneous lesions [3], dermoscopy gains a role in the         the time of inclusion. Persistent erythematous patches,
diagnosis of non-pigmented skin diseases as well, including          plaques, and or nodules with necrosis and ulceration were
inflammatory and infectious diseases [4–6]. Allowing the vi-         the criteria of classic MF. While multiple hypopigmented
sualization of vascular structures, scales, color variegations,      well- defined macules on the trunk with prevalence on
follicular abnormalities, and other structures, dermoscopy           the lower back were the characteristic for hypopigmented
provides a link between clinical evaluation and dermatopa-           variant, hyperpigmented variant represented black col-
thology and is considered an essential device for dermatol-          ored hyperpigmented patches without scaling nor atrophy
ogists in their daily practice [5]. MF has been reported to          or telangiectasias. Localized or diffuse patches comprised
display a different dermoscopic pattern compared to chronic          of atrophy, telangiectasia, hypo or hyperpigmentation
eczema, which represents the main differential diagnosis and         were the clinical criteria in the poikilodermatous variant.
dermoscopy was suggested to facilitate MF diagnosis by               Regarding erythrodermic variant, there was generalized
guiding to a more accurate biopsy for histopathologic exam-          erythroderma while acneiform lesions, cystic comedones,
ination and immunohistochemistry [6].                                alopecia, and follicular papules were the most frequent
                                                                     presentations of folliculotropic variant.
Objectives                                                        3. No prior treatment or no treatment within the last
                                                                     6 months. All patients who accepted to participate in the
This study aimed to investigate the dermoscopic features of          study signed written consent. Exclusion criteria were the
MF, to assess the distribution of these features per clinical        application of any topical treatment, phototherapy, or
variant and to and to correlate these features with histo-           systemic treatment within the last 6 months, pregnancy
pathologic and immunohistochemical alterations.                      or lactation, and the co-existence of other dermatological
                                                                     diseases.

Methods
                                                                     The patients have been classified into the following
This cross-sectional study included a total of 88 patients        ­clinical variants; classic patch stage MF; the commonest vari-
with several clinical variants of MF whose diagnosis was          ant with gradual progression from patches to more infiltrated
based on the clinical presentation of skin lesions and con-       plaques and eventually tumors, hypopigmented MF which is
firmed by histopathological and immunohistochemical ex-           rare and characterized by solely hypopigmented patches or
aminations. After obtaining the research ethics committee         in combination with erythematous patches or plaques, poi-
approval from our faculty of medicine, we included all pa-        kilodermatous MF identified by localized or diffuse large
tients diagnosed with MF at the outpatient clinic, cancer in-     macules and patches of mottled hypopigmentation and hy-
stitute, and private clinics, in the period between November      perpigmentation with atrophy and prominent telangiectasia,
2013 and May 2016.                                                folliculotropic MF; a rare variant frequently presented by
Inclusion criteria were the following:                            folliculotropic infiltrates usually involving the head and neck
                                                                  area, erythrodermic MF which is infrequent with intractable
1. A definitive diagnosis of MF established histopatholog-        progressive erythroderma, and hyperpigmented MF; an ex-
    ically and immunohistochemically. A combination of at         tremely rare variant with hyperpigmented plaques without
    least 3 of the following histopathological criteria is the    poikiloderma.




2                                                                     Original Article | Dermatol Pract Concept. 2023;13(4):e2023284
    All patients were subjected to a thorough dermatological       treatment due to side effects but still have lesions, while the
examination to evaluate the morphology and distribution of         other 56 (63.6%) received no treatment (Table 2).
skin lesions and to exclude any co-existent dermatological
disease. The dermoscopic examination was performed using           Histopathological Examination
Dermlite II PRO HR (3Gen) using polarized light, magnifi-          Histopathological examination of tissue sections stained
cation x10. Digital images of both clinical and dermoscopic        with H&E from MF lesions revealed; all patients (100%)
features of the same MF biopsied lesions were taken by dig-        had atypical lymphocytes, 84 patients (95%) had epidermot-
ital camera Sony: Cyber-Shoot DSC-W690. The selection              ropism escorted with pautrier micro-abscesses, some atyp-
of the dermoscopic variables to be included in the analy-          ical lymphocytes showed arrangement along the epidermal
sis was based on pre-existing literature on dermoscopy of          side of the dermo-epidermal junction in 48 patients (54.5%)
MF, a­ djusted to a consensus paper on the terminology of          and all patients (100%) had atypical dermal infiltrate with
­dermoscopy in general dermatology [5].                            variable density (Figure 1). Overall, all patients presented
    Skin biopsies were taken from all patients; formalin-fixed     with the typical morphological histopathological criteria
routinely processed paraffin-embedded tissue sections (3-5 µ)      recommended by Smoller et al [7].
and prepared on charged glass slides for confirmation of the
diagnosis of MF using light microscopy (Leica DM 500). Im-         Immunohistochemical Examination
munohistochemical staining of tissue sections was conducted        To begin with CD3, all the patients (100%) revealed positive
using antibodies against CD3, CD4, CD8, and CD7 and then           staining. About CD4, 76 (86.4%) patients showed positivity
repeated on a second freshly obtained biopsies after recruit-
ing study participants. All biopsies were obtained from the        Table 1. Classification of the patients according
same sites of dermoscopic examination. Ethical Committee                to mycosis fungoides clinical variant.
in our institution approved the study.
                                                                       Mycosis fungoides variant             No.       %
                                                                    Classic mycosis fungoides                32       36.4
Statistical Analysis                                                (patch stage)
We calculated the sample size according to Raosoft and all          Classic mycosis fungoides                16       18.2
statistical calculations were done using SPSS (statistical pack-    (patch/ tumor stages)
age for the social science version 26.00) statistical program.      Hypopigmented mycosis fungoides          20       22.8
at 0.05, 0.01, and 0.001 level of probability. Qualitative (cat-    Poikelodermatic mycosis fungoides         8        9.1
egorical) data were presented by frequency and percentage
                                                                    Follicultropic mycosis fungoides          4        4.5
was done using chi-square, Pearson linear correlation coef-
                                                                    Erythrodermic mycosis fungoides           4        4.5
ficient (r) was estimated to show the relationship between
                                                                    Hyperpigmented mycosis                    4        4.5
histopathological features (atypical lymphocytes or epider-
                                                                    fungoides
motropism with Pautrier micro-abscesses or alignment of
atypical lymphocytes or atypical dermal infiltrate) and der-
                                                                   Table 2. Distribution of the patients according
moscopic features [9].
                                                                   to demographic data.
                                                                                                       No.             %
Results                                                             Sex
                                                                     Male                               44            50.0
Clinical Results
                                                                     Female                             44            50.0
Out of 88 patients, 48 patients (54.6%) had classic MF, among
                                                                    Age/ year
them 32 (36.4%) presented with the patch stage, and 16
(18.2%) presented with both patch the tumor stages. Twenty           ≤30                                32            36.4

patients (22.8%) had hypopigmented MF, 8 patients (9.1%)             31 – 40                            28            31.8
had poikilodermatous MF, and the study also included 12 pa-          >40                                28            31.8
tients; 4 patients (4.5%) from each of the following: follicu-      Duration/ year
lotropic, erythrodermic, and hyperpigmented MF (Table 1).            ≤ 1 yrs                            32            36.4
    The patients were 44 males (50%) and 44 females                  > 1 yrs – 6 yrs                    48            54.5
(50%). Their ages varied from 10-65 years. The duration              > 6 yrs                             8             9.1
of MF lesions ranged from 3 months-20 years. The num-               Previous treatment
ber of patients who had previous treatment was 32 (36.4%),           No                                 56            63.6%
those patients were either recurrences or who stopped their          Yes                                32            36.4%



Original Article | Dermatol Pract Concept. 2023;13(4):e2023284                                                                  3
                                                                      a. A pink to the erythematous background was found in
                                                                          72 patients (81.8%), a non-homogenous background in
                                                                          68 patients (77.3%), and patchy areas of orange discol-
                                                                          oration in 68 patients (77.3%).
                                                                      Vascular Pattern:
                                                                      b. In 64 patients (72.7%) dermoscopy revealed dotted and
                                                                          short linear vessels, while spermatozoa-like vessels were
                                                                          detected in 44 patients (50%) and arborizing vessels in
                                                                          16 patients (18.2%).
                                                                      Scales:
                                                                      c. Fifty-six patients (63.6%) had patchy whitish scales,
                                                                          while perifollicular and interfollicular scaling was found
                                                                          in 4 patients (4.5%).

Figure 1. H&E of skin biopsy from classic mycosis fungoides (x10);
                                                                      Other Structures:
dermal infiltrate with atypical lymphocytes with alignment at dermo   d. Blue-gray and dark globules were seen in 32 patients
epidermal junction, epidermotropism with Pautrier microabscess.           (36.4%), 20 patients (22.7%) showed focal white struc-
                                                                          tureless areas in 20 patients (22.7%), while white glob-
                                                                          ules were found in 16 patients (18.2%), and red globules
while 12 (13.6%) were with negative staining. 65 (73.9%)                  in 12 patients (13.6%).
of our patients had positive CD8 stains and 23 (26.1%) were               The analytic results of the dermoscopic evaluation according
negative. 84 (95%) patients had a loss of CD7 expression.             to the MF variant are shown in (Table 4). In all of the 48 patients
Finally, the CD4/CD8 ratio was more than 4 in 72 (81.9%)              with classic MF, dermoscopy revealed a pink to erythematous
of the studied patients.                                              background with non-homogeneous distribution. The most fre-
                                                                      quently observed dermoscopic structures were patchy whitish
Dermoscopic Examination                                               scales (44/48, 91.7%), dotted and short linear vessels (44/48,
The analytic results of the dermoscopic evaluation are shown          91.7%), spermatozoa-like vessels (32/48, 66.7%), and patchy
in Table 3. The most frequent dermoscopic features in the to-         areas of orange discoloration, (24/48, 50%) (Figure2).
tal study population were (by category):                                  Concerning the most frequent findings in other
Background Changes:                                                   rare MF variants, the erythrodermic variant exhibited




Table 3. Dermoscopic findings of the studied mycosis fungoides patients.
                                                                                                                     No.         %
 Background changes                    Non-homogenous background                                                      68        77.3
                                       Pink to erythematous background                                                72        81.8
                                       Patchy areas of orange discoloration                                           68        77.3
 Vascular pattern                      Dotted blood vessels                                                           64        72.7
                                       Short linear blood vessels                                                     64        72.7
                                       Spermatozoa like blood vessels                                                 44        50.0
                                       Arborizing blood vessels                                                       16        18.2
 Scales                                Patchy whitish scales                                                          56        63.6
                                       Perifollicular and interfollicular scaling                                      4          4.5
 Globules                              Blue-gray globules                                                             32        36.4
                                       Dark globules                                                                  32        36.4
                                       Patchy red globules                                                            12        13.6
 Pigmentation                          Multifocal pigmentation                                                         4          4.5
                                       Foggy whitish areas                                                            20        22.7
                                       Hypopigmented areas                                                            20        22.7
                                       Pearly white globules                                                          16        18.2
 Structures                            Comedo like openings                                                            4          4.5



4                                                                         Original Article | Dermatol Pract Concept. 2023;13(4):e2023284
                                                                 Table 4. Relation between clinical variants of mycosis fungoides and dermoscopic features.
                                                                                                   Classic MF (patch stage) (n=48)                                                             Other MF variants (n=40)

                                                                                                 Classic-  Classic- patch                          Erythrodermic                                                               Hyperpig-
                                                                         Dermoscopic           patch stage    stage &                                                  Hypopigmented Poikelodermatic Folliculotr-opic           mented
                                                                           features              (n=32)    tumor (n=16) Total              %             (n=4)             (n=20)         (n=8)            (n=4)                 (n=4)     Total   %        P
                                                                     Non-homogenous              100%             100%           48      100.0          100%                 0.00%                  100%               100%     100%       20      50.0   <0.001
                                                                     Background
                                                                     Patchy whitish scales      87.50%            100%           44       91.7          100%                 0.00%                  0.00%              100%     100%       12      30.0   <0.001
                                                                     Perifollicular and          0.00%            0.00%            0        0.0         0.00%                0.00%                  0.00%              100%     0.00%       4      10.0    0.025
                                                                     interfollicular scaling
                                                                     Pink to erythematous        100%             100%           48      100.0          100%                 20.00%                 100%               100%     100%       24      60.0   <0.001
                                                                     background
                                                                     Patchy areas of            87.50%            100%           44       91.7          100%                 20.00%                 100%               100%     100%       24      60.0   <0.001
                                                                     orange discoloration




Original Article | Dermatol Pract Concept. 2023;13(4):e2023284
                                                                     Blue gray globules         37.50%           75.00%          24       50.0          0.00%                0.00%                  0.00%              100%     100%        8      20.0    0.004
                                                                     Dark globules              37.50%           75.00%          24       50.0          0.00%                0.00%                  0.00%              100%     100%        8      20.0    0.004
                                                                     Patchy red globules        12.50%           25.00%            8      16.7          100%                 0.00%                  0.00%              0.00%    0.00%       4      10.0    0.364
                                                                     Multifocal                  0.00%            0.00%            0        0.0         0.00%                0.00%                  0.00%              0.00%    100%        4      10.0    0.025
                                                                     pigmentation
                                                                     Foggy whitish areas         0.00%            0.00%            0        0.0         0.00%                 100%                  0.00%              0.00%     0%        20      50.0   <0.001
                                                                     Comedo like                 0.00%            0.00%            0        0.0         0.00%                0.00%                  0.00%              100%     0.00%       4      10.0    0.025
                                                                     openings
                                                                     Hypopigmented               0.00%            0.00%            0        0.0         0.00%                 100%                  0.00%              0.00%    0.00%      20      50.0   <0.001
                                                                     areas
                                                                     Pearly white globules      12.50%            0.00%            4        8.3         0.00%                60.00%                 0.00%              0.00%    0.00%      12      30.0    0.009
                                                                     Dotted blood vessels       87.50%            100%           44       91.7          100%                 0.00%                  100%               100%     100%       20      50.0   <0.001
                                                                     Short linear blood         87.50%            100%           44       91.7          100%                 0.00%                 50.00%              100%     100%       20      50.0   <0.001
                                                                     vessels
                                                                     Spermatozoa like           50.00%            100%           32       66.7          100%                 0.00%                 50.00%              100%     0.00%      12      30.0    0.001
                                                                     blood vessels
                                                                     Arborizing blood            0.00%            0.00%            0        0.0         100%                 0.00%                  100%               100%     0.00%      16      40.0   <0.001
                                                                     vessels
                                                                 a
                                                                 P p-value for Chi-square test for comparing between the different categories, significant at p-value < 0.05, highly significant at p-value < 0.001.




5
        Figure 2. (A) Male patient presented with classic mycosis fungoides, showing multiple erythematous scaly plaques on trunk.
        (B) Dermoscopic features of lesions on the trunk; patchy whitish scales (black arrows), spermatozoa like blood vessels
        (­yellow arrow), and short linear blood vessels (blue arrow) on pink to erythematous background, polarized light x10.



non-homogenous pink to erythematous background (4/4,                  Conclusions
100%), dotted, short linear, spermatozoa like and arboriz-
ing blood vessels (4/4, 100%). (Figure 3) The hypopigmented           Our study provides novel insights into the dermoscopic mor-
variant was characterized by foggy whitish areas (20/20,              phology of MF according to the clinical variant. Overall, our
100%), hypopigmented areas (20/20, 100%), and pearly                  results are consistent with pre-existing evidence [10].
white globules (12/20, 60%). The poikilodermatous variant                 Classic patch stage MF was dermoscopically typified by a
revealed patchy areas of orange discoloration (8/8, 100%),            pink to erythematous background, patchy orange-yellowish
dotted (8/8, 100%), and arborizing blood vessels (8/8,                color, patchy whitish scales, dotted and fine short linear ves-
100%), folliculotropic variant (Figure 4) presented perifol-          sels. These results are in perfect agreement with the previous
licular and interfollicular scaling (4/4, 100%), comedo-like          study by Lallas et al [10]. However, a pink to erythematous
openings (4/4, 100%), dotted, short linear, spermatozoa like          background, which results from dilatation of dermal blood
(Figure 5) and arborizing blood vessels (4/4, 100%), hyper-           vessels, was found to be not specific for MF, since it is also
pigmented variant showed blue-gray globules (4/4, 100%),              frequent in psoriasis, chronic dermatitis, and lichen pla-
dark globules (4/4, 100%), dotted and short linear blood              nus [11].
vessels (4/4, 100%). Regarding the correlation between the                Patchy areas of orange discoloration which represent se-
frequently encountered dermoscopic features of MF with his-           rum oozing from erosions [12], were observed in the patch
topathological findings (Table 5); non-homogeneous back-              stage of classic MF. This feature was previously suggested as
ground, showed a statistically significant moderately positive        a significant criterion for the differential diagnosis between
correlation with the presence of atypical dermal infiltrates          MF and chronic dermatitis [10]. In our study, we did observe
(ADI) (P < 0.001), while showed a weak positive correla-              this feature in all clinical variants of MF without significant
tion with atypical lymphocytes (AL), epidermotropism and              differences among them.
Pautrier microabscesses (E and PMA) and alignment of atyp-                Dotted and short linear blood vessels, that correlate with
ical lymphocytes (AAL) with high statistical significance ( P         vertical vessels [12] and tumor angiogenesis [11] respectively,
0.003, 0.33 and 0.006, respectively). Patchy whitish scales           were observed mostly in patients with patch stage of classic
showed a statistically significant strong positive correlation        MF. Also, the peculiar vascular structure consisting of a dot-
with AL, E, PMA, AAL, and ADI (P < 0.001). Pink to er-                ted and a linear vessel (spermatozoa like blood vessels) were
ythematous background showed a strong positive correla-               observed in 66.7% of classic MF patients, and 30% of other
tion with AL and E, PMA (P < 0.001), on the other hand,               rare MF variants including erythrodermic, folliculotropic,
showed a weak positive correlation to AAL and ADI (P =                and poikilodermatous variants. This feature was previously
0.03). Patchy areas of orange discoloration and short linear          described as a dermoscopic characteristic of classic MF, but
blood vessels showed a strong positive correlation with all           it has not been reported in other MF variants.
findings which was highly statistically significant (P < 0.001).          We detected patchy whitish scales, that correspond to
Spermatozoa-like blood vessels showed a strong positive cor-          areas of parakeratosis [11], in classic, erythrodermic, fol-
relation with AL, E, and PMA (P < 0.001) and a moderately             liculotropic, and hyperpigmented variants of MF. This is in
strong positive correlation to both AAL and ADI (P < 0.001).          line with the study by Saleh MA and Abdel Halim DM who



6                                                                          Original Article | Dermatol Pract Concept. 2023;13(4):e2023284
Figure 3. (A) Female patient presented with erythrodermic mycosis fungoides, with erythema and scales on the face. (B) Dermoscopic
features of lesions of the face; dotted blood vessels (red arrows), patchy whitish scales (yellow arrow), and spermatozoa like blood vessels
(blue arrows), all on non-homogenous pink background, polarized light x10. (C) The same patient with erythema on the back of the legs.
(D) Dermoscopic features of lesions of the legs; dotted blood vessels (yellow arrow), and spermatozoa like blood vessels (white arrow) on
non-homogenous pink background, polarized light x10.



observed these scales in classic and hyperpigmented variants.               Blue-gray globules were also detected in folliculo-
As scales were observed in MF as well as some inflamma-                 tropic variant, which is a novel finding in the literature.
tory skin diseases, they were not specific for MF diagnosis             In ­addition, the folliculotropic variant was characterized
[10,11].                                                                by perifollicular, interfollicular scaling, and comedo-like
    Dermoscopic examination of hyperpigmented MF re-                    openings that represent keratin filled invagination of the
vealed multifocal pigmentation and dark and blue-gray                   epidermis [13] and could be found in many scalp and hair
globules that represent epidermal or horny layer melanin                disorders [14]. Still, they are not specific for MF diagnosis,
or blood and melanophages in the papillary dermis respec-               they may differentiate folliculotropic variant from other
tively [11]. This was observed previously by Saleh and Abdel            variants.
Halim. Thus, it can be concluded that these globules are of                 The hypopigmented variant of MF showed whitish areas
value in the diagnosis of the hyperpigmented variant.                   that represent areas of hypomelanosis [12], and pearly white



Original Article | Dermatol Pract Concept. 2023;13(4):e2023284                                                                            7
    Figure 4. (A) Male patient presented with folliculotropic mycosis fungoides, showing erythematous scaly plaques behind the left ear.
    (B) ­Dermoscopic features of the postauricular area; pink to erythematous background with areas of orange discoloration (black ar-
    rows), patchy white scales (yellow arrows), arborizing blood vessels (white arrows), spermatozoa like blood vessels (green arrow) and
    short linear blood vessels (blue arrow), polarized light x10. (C) The same patient with hairless plaque on the scalp. (D) Dermoscopic
    features of the scalp lesions; inter and perifollicular scaling (red arrows) and large blue-gray globules (yellow arrow). Polarized light x10.




             Figure 5. Dermoscopic features of poikilodermatous mycosis fungoides showing spermatozoa like blood vessels
             (black arrows).


8                                                                                 Original Article | Dermatol Pract Concept. 2023;13(4):e2023284
Table 5. Correlation between dermoscopic and histopathological features (H&E stain).
       Dermoscopic Features                                                 Histopathological Features
                                                                 Epidermotropism                 Alignment
                                              Atypical             With Pautrier                 of Atypical         Atypical Dermal
                                            Lymphocytes           Microabscesses                Lymphocytes             Infiltrate
                                              R           P             r             P          r           P           r           P
 Non-homogenous Background                 0.312        0.003      0.227           0.033       .289       0.006       0.627       0.000
 Patchy whitish scales                       .889       0.000       .883           0.000       .930       0.000        .889       0.000
 Perifollicular and interfollicular          .219       0.040       .227           0.033       .308       0.003        .965       0.000
 scaling
 Pink to erythematous background             .965       0.000       .963           0.000       .308       0.003        .308       0.003
 Patchy areas of orange                    1.000        0.000      1.000           0.000       .937       0.000        .937       0.000
 discoloration
 Blue-gray globules                          .646       0.000       .671           0.000       .937       0.000        .937       0.000
 Dark globules                               .646       0.000       .671           0.000       .690       0.000        .690       0.000
 Patchy red globules                         .384       0.000       .399           0.000       .594       0.000        .646       0.000
 Multifocal pigmentation                     .219       0.040       .227           0.033       .482       0.000        .482       0.000
 Foggy whitish areas                         .502       0.000       .521           0.000       .339       0.001        .339       0.001
 Hypopigmented areas                         .219       0.040       .227           0.033       .690       0.000        .690       0.000
 Pearly white globules                       .502       0.000       .521           0.000       .690       0.000        .963       0.000
 Dotted blood vessels                        .446       0.000       .463           0.000       .594       0.000        .646       0.000
 Short linear blood vessels                  .963       0.000       .962           0.000       .855       0.000        .772       0.000
 Spermatozoa like blood vessels              .963       0.000       .962           0.000       .482       0.000        .446       0.000
 Arborizing blood vessels                    .772       0.000    .802              0.000       .289       0.006       0.627       0.000



globules. These features, that were not reported before in              dermoscopic images offer a horizontal assessment. Therefore, it
any previous study, can differentiate hypopigmented variant             is always hard to correlate both tools, however, the horizontal
from other variants of MF.                                              perception which is added by dermoscopy is complementary to
    Regarding the pearly white globules, an interesting ob-             histopathology [11]. Dermoscopy is similarly valuable in barely
servation in the present study in some patients who previ-              visible vascular components and color deviations so it may as-
ously received phototherapy; was observed before in the                 sociate clinical examination and dermatopathology [17].
active vitiligo lesions [15,16] and it was described by Jha                   Our study has several limitations. First, we included
et al as “tapioca sago” appearance [15]. We suggest that it             only MF cases and, therefore, our results do not provide
may be a sign of photodamaging. This relates to Friedland R             information on the usefulness of described criteria for the
et al who stated that MF patients who were treated with                 differential diagnosis between MF and clinical simulators.
phototherapy may acquire an eruption resembling idiopathic              Besides, some rare clinical variants included in the study
guttate hypomelanosis as a side effect [16].                            were represented by a small sample, which did not allow a
    Another noteworthy finding of our analysis was that all             more robust statistical analysis to assess differences among
MF variants except hypopigmented MF were characterized                  clinical variants.
by a non-homogenous distribution of structures and colors.                    In conclusion, our study confirms previous evidence on
Malvehy et al stated that the non-homogenous distribution               dermoscopy of MF and provides novel information on the
of structures and colors was not observed previously in the             distribution of the dermoscopic criteria according to the clin-
dermoscopic examination of benign skin disorders [12].                  ical variant, which might be clinically relevant.
Thus, it could be added as a dermoscopic feature indicative
of malignancy.                                                          References
    Our analysis revealed a very good correlation between
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