10.5826/dpc.1401a63
Introduction: Dermatoscopy is a frequently used non-invasive diagnostic procedure.
Objectives: Considering that mycosis fungoides (MF) mimics parapsoriasis clinically in  early stages, we aim to determine the dermatoscopic criteria and the histopathological correlations in patients with MF and small plaque parapsoriasis (SPP).
Methods: This prospective study involved 28 patients with clinical and histopathological diagnoses of MF and 31 patients with SPP. Videodermoscopy and USB capillaroscope were used to evaluate the patients vessels at ×200 magnification. Vascularity was evaluated through microvascular density (MVD) scoring involving CD34 antibody staining.
Results: Fifty-nine patients were included in this study. The scores corresponding to the presence of short linear vessels, linear-curved vessels, branching linear vessels, and non- structured orange-colored areas were significantly higher in the MF patients than in the SPP patients (P &lt; 0.05). The highest MVD (P = 0.01) scores were also higher in the MF patients than in the SPP patients.
Conclusions: The SPP and early-stage MF patients differed in their MVD scores, and the findings correlated with the dermatoscopy and lesional capillaroscopy findings. Differentiating features between SPP and MF were thus identified.
text/xml
2160-9381
3560
en
Ayşe Esra Koku Aksu
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
parapsoriasis
Dermatoscopic Characteristics, Lesional Capillaroscopic Features, and Histopathological Correlation of Small Plaque Parapsoriasis and Mycosis Fungoides
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2024-01-31
2023-05-23
2024-01-31
2024-02-21
e2024063
Dermatol Pract Concept
Introduction: Dermatoscopy is a frequently used non-invasive diagnostic procedure.
Objectives: Considering that mycosis fungoides (MF) mimics parapsoriasis clinically in  early stages, we aim to determine the dermatoscopic criteria and the histopathological correlations in patients with MF and small plaque parapsoriasis (SPP).
Methods: This prospective study involved 28 patients with clinical and histopathological diagnoses of MF and 31 patients with SPP. Videodermoscopy and USB capillaroscope were used to evaluate the patients vessels at ×200 magnification. Vascularity was evaluated through microvascular density (MVD) scoring involving CD34 antibody staining.
Results: Fifty-nine patients were included in this study. The scores corresponding to the presence of short linear vessels, linear-curved vessels, branching linear vessels, and non- structured orange-colored areas were significantly higher in the MF patients than in the SPP patients (P &lt; 0.05). The highest MVD (P = 0.01) scores were also higher in the MF patients than in the SPP patients.
Conclusions: The SPP and early-stage MF patients differed in their MVD scores, and the findings correlated with the dermatoscopy and lesional capillaroscopy findings. Differentiating features between SPP and MF were thus identified.
Ayşe Esra Koku Aksu
2024/01/31
10.5826/dpc.1401a63
e2024063
Department of Dermatology, University of Health Sciences, Istanbul Teaching and Research Hospital, İstanbul, Turkey 
2160-9381
parapsoriasis
en
e2024063
Väkevä L, Sarna S, Vaalasti A, Pukkala E, Kariniemi AL, Ranki A. A retrospective study of the probability of the evolution of parapsoriasis en plaques into mycosis fungoides. Acta Derm Venereol. 2005;85(4):318-323. DOI: 10.1080/00015550510030087. PMID: 16191852.
Dermatoscopic Characteristics, Lesional Capillaroscopic Features, and Histopathological Correlation of Small Plaque Parapsoriasis and Mycosis Fungoides
https://dpcj.org/index.php/dpc/article/download/3560/2428
         Dermatoscopic Characteristics, Lesional
      Capillaroscopic Features, and Histopathological
        Correlation of Small Plaque Parapsoriasis
                  and Mycosis Fungoides
            Dilara İlhan Erdil1, Merve Cin2, Duygu Erdil1, Vildan Manav1, Buğra Burç Dağtaş1,
                                           Ayşe Esra Koku Aksu1


1 Department of Dermatology, University of Health Sciences, Istanbul Teaching and Research Hospital, İstanbul, Turkey
2 Department of Pathology, University of Health Sciences, Istanbul Teaching and Research Hospital, İstanbul, Turkey



Key words: dermoscopy, dermoscopic patterns, capillaroscopy, mycosis fungoides, parapsoriasis
Citation: İlhan Erdil D, Cin M, Erdil D, Manav V, Dağtaş BB, Koku Aksu AE. Dermatoscopic Characteristics, Lesional Capillaroscopic Features,
and Histopathological Correlation of Small Plaque Parapsoriasis and Mycosis Fungoides. Dermatol Pract Concept. 2024;14(1):e2024063. DOI:
https://doi.org/10.5826/dpc.1401a63
Accepted: November 11, 2023; Published: January2024
Copyright: ©2024 İlhan Erdil 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: This study was funded by Istanbul Teaching and Research Hospital for immunohistochemical studies.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Dilara İlhan Erdil, MD. Istanbul Teaching and Research Hospital, Department of Dermatology, Kasap İlyas Mah. Org.
Abdurrahman Nafiz Gu rman Cd. PK: 34098, Istanbul, Turkey. Phone number: +905413713776. Fax: +9002126320060, E-mail:dilara2021@gmail.
com




  ABSTRACT               Introduction: Dermatoscopy is a frequently used non-invasive diagnostic procedure.
                         Objectives: Considering that mycosis fungoides (MF) mimics parapsoriasis clinically in early stages,
                         we aim to determine the dermatoscopic criteria and the histopathological correlations in patients with
                         MF and small plaque parapsoriasis (SPP).
                         Methods: This prospective study involved 28 patients with clinical and histopathological diagnoses of
                         MF and 31 patients with SPP. Videodermoscopy and USB capillaroscope were used to evaluate the pa-
                         tients vessels at ×200 magnification. Vascularity was evaluated through microvascular density (MVD)
                         scoring involving CD34 antibody staining.
                         Results: Fifty-nine patients were included in this study. The scores corresponding to the presence of
                         short linear vessels, linear-curved vessels, branching linear vessels, and non- structured orange-colored
                         areas were significantly higher in the MF patients than in the SPP patients (P < 0.05). The highest
                         MVD (P = 0.01) scores were also higher in the MF patients than in the SPP patients.
                         Conclusions: The SPP and early-stage MF patients differed in their MVD scores, and the findings
                         correlated with the dermatoscopy and lesional capillaroscopy findings. Differentiating features
                         ­
                         ­between SPP and MF were thus identified.


Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                                                  1
Introduction                                                        those younger than 18 years, or those who received topi-
                                                                    cal treatment within the last 2 weeks or systemic treatment
Primary cutaneous T-cell lymphomas (CTCLs) are a hetero-            within the last 4 weeks were excluded.
geneous group of clonal T-cell lymphoproliferative diseases.
Mycosis fungoides (MF), which is the most frequent sub-             Dermatoscopic and Lesional Capillaroscopic Imaging
type of CTCL, constitutes 50–65% of all CTCL cases [1].             At least 2 images were taken from the MF or SPP lesions of
Early-stage MF is difficult to diagnose because it can mimic        the included patients by using a FotoFinder videodermato-
various diseases, such as parapsoriasis, contact dermatitis,        scope (FotoFinder Systems GmbH) and a Dino- lite Capil-
and pigmented purpuric dermatosis [2], and the histopatho-          laroscope Pro 200 (MEDL4N Pro). Images were taken both
logical findings of early-stage MF may be vague or focal.           from the intact perilesional skin and lesional skin. The skin
Moreover, MF diagnosis is usually delayed, commonly after           biopsy site was evaluated through videodermatoscopy and
the mean onset of signs [1]. Thus, additional methods that          was selected within the area with the highest vascularity.
can aid in diagnosis are needed.                                    Minimal pressure was applied to evaluate the vascular mor-
    One of the most challenging differential diagnosis of MF        phology. To ensure the visibility of the scales, we obtained
is small plaque parapsoriasis (SPP) [3]. Also called digitate       videodermatoscopy images from dry and wet (with alcohol)
dermatosis or chronic superficial scaly dermatitis, SPP differs     mount samples. Then, a 4 mm punch biopsy was obtained
from MF on the basis of its being a benign chronic condition [4].   from this marked area. The presence of vascular structures
Repeated skin biopsies may be required to differentiate MF          (short linear, linear curved, dotted, and branching linear ves-
from SPP. Meanwhile, data on histopathological correlation          sels), the follicular findings, the occurrence of a structure-
in dermatoscopy remain limited [3]. Thus, studies involving         less orange/white/purple- colored area, and the presence and
videodermatoscopy and lesional capillaroscopy performed             localization of scale were recorded. Vascular dermoscopic
at high magnifications are needed to determine the criteria         finding or structureless orange area were categorized based
for discrimination. Given that vascular structures in MF can        on whether the percentage of occurrence was below or above
be observed more clearly with dermatoscopy, MF could pos-           50%. Additionally, the vascular pattern, scale localization
sibly be differentiated from SPP by dermatoscopy or lesional        and morphology of the structureless orange area were as-
capillaroscopy [3]. In addition, histopathological correla-         sessed by subdividing them into the morphological sub-
tion with vascular structures was analyzed in the marked            groups. Dermatoscopic terminology outlined in this study
­dermatoscopic imaging areas.                                       are in accordance with the standardized dermatoscopic ter-
                                                                    minology established by an expert consensus on behalf of the
Objectives                                                          International Dermoscopy Society [5].

In this study, we aimed to detect dermatoscopic and lesional        Histopathological Evaluation
capillaroscopic features in patients with MF and SPP and            Paraffin-embedded blocks and hematoxylin and eosin-
correlate these findings with histopathology.                       stained preparations were evaluated by an experienced der-
                                                                    matopathologist, who was blinded to the clinical data of

Methods                                                             the cases.
                                                                       Histopathological evaluation involved the assessment of
This prospective, observational, and cross-sectional study,         epidermal changes, atypical lymphocytic infiltration, dermal
which was approved by the local ethics committee, included          fibrosis, localization of dermal infiltration, loss of CD7, and
59 patients who gave a written consent allowing the publi-          expression of CD30. Immunohistochemical evaluations in-
cation of their case details. The included patients were those      volved CD3, CD4, CD8, CD7, CD30, and CD34 antibody
who attended the dermatology outpatient clinic between Oc-          staining.
tober 2021 and June 2022 and were diagnosed clinically and
histopathologically as having early-stage MF (N = 28) and           Immunohistochemical Evaluation
SPP (N = 31).                                                       Four micrometer-thick sections were prepared from
    The inclusion criteria were as follows: clinically and          paraffin-embedded blocks and then stained with CD3 an-
histopathologically diagnosis of MF or SPP, having patch/           tibody (clone: 2GV6, Ventana Medical Systems), CD4
plaque lesions for MF patients and having patch lesions for         antibody (clone: SP35, Ventana Medical Systems), CD8
SPP patients, at least 18-year-old, and without any topical         antibody (clone: SP57, Ventana Medical Systems), CD7 an-
treatment within the last 2 weeks or any systemic treatment         tibody (clone: SP94, Ventana MedicalSystems) and CD30
within the last 4 weeks. Patients who could not be diagnosed        antibody (clone: Ber-H2, Ventana Medical Systems) for diag-
as having MF or SPP both clinically and histopathologically,        nostic purposes and stained with CD34 (clone: Qend/10 Cell



2                                                                       Original Article | Dermatol Pract Concept. 2024;14(1):e2024063
Marque) for visualization of dermal microvessels. For sec-         was performed to determine the threshold value for MF. A P
ondary imaging, the Standard UltraView IHC Protocol was            value less than 0.05 indicated statistical significance.
applied and a Roche/UltraView Universal DAB Detection
Kit was used; all operations were performed on a ROCHE/­           Results
Ventana BenchMark XT IHC Stainer device.                           This study included 59 patients, of whom 47.5% had MF
    CD34 expression was observed in the cytoplasm and cell         and 52.5% had SPP. Of the MF and SPP patients, 39.3% and
membrane of the endothelial cells of dermal microvessels.          48.4% were women, respectively. For the MF patients, the
Since lymphatic/vascular endothelium differentiation was           mean age at diagnosis was 55.2±13.2 years, the age of lesion
not possible, structures with unidentifiable lumens or weak        onset was 47.6±13.3 years, and the mean time to diagnosis
cytoplasmic staining (such as fibroblasts) were excluded           was 78.9±100.1 months. For the SPP patients, the mean age
from the counting. Counting was performed manually and             of lesion onset was 48.1±17.4 years. The total number of bi-
comparisons were made with H&E stained preparations                opsies taken was significantly higher in MF (5/patient) than
when necessary. All slides were initially scanned at low           in SPP (2.5/patient) (P < 0.05). The follow-up period was
power magnification (×40) to identify the hot spot areas (ar-      also longer in the MF patients (71.1±72 months) than in the
eas showing the greatest degree of CD34 staining). Vascular        SPP patients (27±39 months) (P < 0.05). Of the MF patients,
structures stained with CD34 were counted in these areas           82.2% are in stage 1A at the time of diagnosis.
at x200 magnification (0.95 mm2 ).Three non- overlapping              The demographic and clinical data of the patients are
hot spot areas were examined (2.85 mm2) and the areas with         summarized in Table 1.
the highest microvascularity and the sum of the number of
microvessels in these three areas were determined. Moreover,       Dermatoscopy and Lesional Capillaroscopy
CD30 expressing cells were identified among the lymphoid           Short linear vessels were observed in 85.7% of the MF
cells in the lesion area.                                          patients, and 39.2% of them had short linear vessels cov-
                                                                   ering >50% of the lesion (P = 0.001). Among the SPP pa-
Statistical Analysis                                               tients, 45.1% had short linear vessels and proportionally
Statistical analysis was performed using SPSS version 23.0.        only 9.6% of them had vessels covering >50% of the lesion
The conformity of the variables to the normal distribution         (P = 0.002). Linear curved vessels were found in 53.5%
was evaluated using the Kolmogorov–Smirnov/Shapiro–                and 19.3% of the MF and SPP patients (P = 0.006), respec-
Wilk test. Independent sample t-test and Mann–Whitney U            tively, and they were proportionally present in >50% of the
test were used to compare the normally and non-normally            lesion in 35.7% and 16.1% of the MF and SPP patients
distributed variables of the two groups. The categorical           (P = 0.018), respectively. Dotted vessels were frequently
variables were analyzed using chi-square (exact) test. The         observed in MF and SPP, and no difference was found be-
Bonferroni multiple comparison test was used to determine          tween the two diseases. Branching linear vessels were found
the significant difference between the groups. ROC analysis        in 39.2% of the MF cases and rarely did they cover >50%




   Table 1. Demographic and clinical features of mycosis fungoides and small plaque parapsoriasis.
                                                          Mycosis fungoides                   Parapsoriasis
                                                           N              %                  N                %               P
 Gender                               Female               11          (39.29)              15              (48.39)       0.48
                                      Male                 17          (60.71)              16              (51.61)
 Age at diagnosis, mean ± SD/median (range)          55.22±13.19      58 (24-74)
 Age of first lesion                                 47.61±13.33      44 (22-70)       48.19±17.43        50 (18-79)      0.88
 Time (months) until diagnosis, mean ± SD           78.89±100.16      36 (0-360)
 Total number of skin biopsy, mean ± SD                5.07±3.52      4.5 (1-13)        2.52±2.19          2 (1-11)       0.002
 Follow-up duration, mean ± SD                       71.11±72.30      36 (3-192)       27.03±38.97         9 (1-144)      0.027
 Stage at diagnosis                   1A                   23          (82.14)
                                      2A                    5          (17.86)
 Lymph node involvement               None                 23          (82.14)
                                      Present               5          (17.86)

SD = standard deviation.



Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                                    3
of the lesions (7.1%). In SPP, branching linear vessels were        Those patients with an MVD score (the total score for three
found only in 12.9% of the lesions, and only 3.2% of                fields) higher than 51.5 were classified as having MF, with
these cases had the vessels covering >50% of the entire le-         64.3% sensitivity and 71.0% specificity. The area under the
sion (P = 0.040). While a peripheral, uniform, clustered, or        curve was 70.3%, which was significant (P < 0.05; 95%CI
non-specific vascularity pattern was rarely absent in most          (0.569–0.837). Those with short linear vessels were clas-
MF patients (7.1%), a vascularity pattern was often not             sified as having MF, with 85.21% sensitivity and 54.8%
observed in SPP patients (38.7%) (P = 0.026). Moreover,             specificity and an area under the curve of 70.3% (P < 0.05;
patchy, orange-colored areas were larger in the MF patients         95%CI (0.568–0.838). Those with linear curved vessels were
(82.1%) than in the SPP patients (48.4%), and purple color-         classified as having MF, with a sensitivity of 53.6% and a
ation was more frequently observed in the MF patients than          specificity of 80.6%. The area under the curve was 67.1%,
in the SPP patients (P = 0.024). No significant difference          which was significant (P < 0.05; 95%CI (0.531–0.812). The
was observed between the groups in terms of purpuric area,          area under the curve for the branching linear vessels was not
presence of scale, localization of scale, follicular findings, or   significant (P > 0.05) (Table 5).
in the other variables included in Table 2 (P > 0.05) (Table 2
and Figure 1).
                                                                    Conclusions
Histopathology                                                      In our study, clinical, dermatoscopic, lesional capillaro-
CD7 loss was significantly higher in the MF patients (57.1%)        scopic, and histopathological findings were evaluated for the
than in the SPP patients (25.8%) (p=0.014), whereas CD30            differentiation of MF and SPP. Among the CTCLs, MF is
expression was not detected in any patient. The presence of         the most common subtype and is diagnosed based on clin-
spongiosis was significantly lower in the MF patients than in       ical and histopathological findings [6]. Given that the find-
the SPP patients (p=0.029). By contrast, lymphocytic infiltra-      ings may be focal or may mimic a wide variety of benign
tion with large/convoluted nuclei was significantly higher in       dermatoses, histopathological diagnosis might be difficult
the MF patients than in the SPP patients (p<0.001). The two         to achieve despite the use of advanced algorithms [7-9].
groups did not significantly differ in terms of dermal fibrosis.    Therefore, the time from the appearance of lesions to the
The rates of perivascular infiltration and band-type infiltra-      diagnosis of MF is variable and can take between 24 and
tion were significantly lower and higher (p<0.001), respec-         51 months. It has even been reported to be approximately
tively, in the MF patients than in the SPP patients (­Table 3       4 years on average [10-13]. In our study, this period was
and Figure 2).                                                      even longer, with an average of 6.5 years (79 months). There-
                                                                    fore, additional tests are required for early diagnosis. All of
                                                                    our patients had early-stage MF. Compared with advanced
Microvascular Density Scores
                                                                    stages, early-stage MF requires various differential diagnosis
The MF patients had higher microvascular density (MVD)
                                                                    to distinguish it from benign dermatoses, hence the need for
scores than the SPP patients (23.6±9.8 and 18±8.1, respec-
                                                                    repeated biopsies [14]. In this study, twice as many biopsies
tively) (P = 0.010), as revealed by CD34 staining. Similarly,
                                                                    were performed in the MF patients as in the SPP patients. In
the total MVD score for the three areas with the highest
                                                                    a study, the first biopsy taken was diagnostic in only 25%
scores was significantly higher in the MF patients than in
                                                                    of the cases, with a mean diagnostic delay of 2.3 years. Re-
the SPP patients (59±24.2 and 43.9±16.8, respectively)
                                                                    gardless of the number of biopsies taken, the probability of a
(P = 0.07) (Table 3).
                                                                    biopsy resulting in MF was also 25%. This delay in diagnosis
                                                                    was attributed not to the time of biopsy but to the difficulty
Dermatoscopy and Histopathology Correlation                         in histopathological diagnosis [13].
The Guitart score (P = 0.011) for the presence of short linear         Our knowledge about CTCL dermoscopy has increased
vessels was significantly higher than that for their absence        in recent years. MF dermatoscopy is especially valuable at
(Figure 3). The Guitart score for the presence of linear curved     early stages when findings are ambiguous. In this study, short
vessels was also significantly higher than that for their ab-       linear vessels, linear curved vessels (spermatozoa-like ves-
sence (P = 0.007). Similarly, the Guitart and MVD scores for        sels), and branching linear vessels were more frequently ob-
the presence of branching linear vascularization were signifi-      served in the MF patients than in the SPP patients (p<0.05).
cantly higher than those for their absence (Table 4).               According to Lallas et al.spermatozoa-like vessels are highly
    Those patients with an MVD score (highest score) higher         specific for MF [15]. In another study involving patients
than 20 were classified as having MF, with 67.9% sensitivity        with early-stage MF, linear and spermatozoa-like vascular
and 67.7% specificity. The area under the curve was 69.6%,          structures and yellow- orange-colored areas were also com-
which was significant (P < 0.05; 95%CI (0.560–0.831)).              monly observed [16].



4                                                                       Original Article | Dermatol Pract Concept. 2024;14(1):e2024063
               Table 2. Dermoscopy and lesional capillaroscopy findings of mycosis fungoides
                                       and parapsoriasis patients.
                                                                 Mycosis fungoides     Parapsoriasis
                                                                  N           %       N            %               P
 Short linear vessel                      None                     4        (14.29)   17        (54.84)          0.001
                                          Present                 24        (85.71)   14        (45.16)
 Short linear vessel ratio                None                     4        (14.29)   17        (54.84)          0.002
                                          <%50                    13        (46.43)   11        (35.48)
                                          >%50                    11        (39.29)   3          (9.68)
 Linear curved vessel                     None                    13        (46.43)   25        (80.65)          0.006
                                          Present                 15        (53.57)   6         (19.35)
 Linear curved vessel ratio               None                    13        (46.43)   25        (80.65)          0.018
                                          <%50                     5        (17.86)   1          (3.23)
                                          >%50                    10        (35.71)   5         (16.13)
 Dotted vessels                           None                     9        (32.14)   16        (51.61)          0.131
                                          Present                 19        (67.86)   15        (48.39)
 Dotted vessels ratio                     Yok                     10        (35.71)   16        (51.61)          0.186
                                          <%50                     9        (32.14)   11        (35.48)
                                          >%50                     9        (32.14)   4         (12.90)
 Branching linear vessels                 None                    17        (60.71)   27        (87.10)          0.020
                                          Present                 11        (39.29)   4         (12.90)
 Branching linear vessels                 None                    17        (60.71)   27        (87.10)          0.040
                                          <%50                     9        (32.14)   3          (9.68)
                                          >%50                     2         (7.14)   1          (3.23)
 Vascularity pattern                      None                     2         (7.14)   12        (38.71)          0.026
                                          Peripheral               1         (3.57)   0          (0.00)
                                          Uniform                  6        (21.43)   2          (6.45)
                                          Clustered                1         (3.57)   0          (0.00)
                                          Non-specific            18        (64.29)   17        (54.84)
 Purpuric area                            None                    21        (75.00)   29        (93.55)          0.071
                                          Present                  7        (25.00)   2          (6.45)
 Presence of scale                        None                    17        (60.71)   22        (70.97)          0.406
                                          Present                 11        (39.29)   9         (29.03)
 Localization of scale                    None                    17        (60.71)   22        (70.97)          0.609
                                          Patchy                   6        (21.43)   6         (19.35)
                                          Diffuse                  5        (17.86)   3          (9.68)
 Follicular findings                      None                    24        (85.71)   30        (96.77)          0.180
                                          Present                  4        (14.29)   1          (3.23)
 Dilated follicle                         None                    26        (92.86)   31        (100,00)         0.221
                                          Present                  2         (7.14)   0          (0.00)
 Structureless orange area                None                     6        (21.43)   16        (51.61)          0.017
                                          Present                 22        (78.57)   15        (48.39)
 Structureless orange area ratio          None                     6        (21.43)   15        (48.39)          0.049
                                          <%50                    17        (60.71)   10        (32.26)
                                          >%50                     5        (17.86)   6         (19.35)
 Structureless orange area feature        None                     4        (14.29)   11        (35.48)          0.024
                                          Patchy                  23        (82.14)   15        (48.39)
                                          Diffuse                  1         (3.57)   5         (16.13)

                                                                                                           Table2 continues


Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                           5
    Table 2. Dermoscopy and lesional capillaroscopy findings of mycosis fungoides and parapsoriasis
                                        patients. (continued)
                                                               Mycosis fungoides                   Parapsoriasis
                                                                  N               %               N               %               P
 Structureless white area                 None                   19            (67.86)            27           (87.10)         0.075
                                          Present                  9           (32.14)             4           (12.90)
 Purple color                             None                   20            (71.43)            29           (93.55)         0.036
                                          Present                  8           (28.57)             2            (6.45)
 Brown reticular network/                 None                   25            (89.29)            31           (100.00)        0.101
 poikiloderma                             Present                  3           (10.71)             0            (0.00)




Figure 1. (A) Purple and white areas, minimal linear short vessels in a case of mycosis fungoides (MF) case with videodermoscopy.
(B) ­Linear-curved vessels in MF case with videodermoscopy. (C) Branching linear vessels in facial syringotropic MF case with videodermos-
copy. (D) Scales in grooves and linear-curved vessels with lesional capillaroscopy.


    In yet another study, spermatozoa-like linear vessels were         the patch stage to the tumoral stage, linear vessels begin to
frequently detected in patch- stage MF, and this characteristic        branch out, and linear curved vessels in plaque lesions become
could effectively differentiate MF from other benign dermato-          difficult to observe via dermatoscopy. These vessels are the fine
ses. Additionally, dermatoscopic patterns were compared ac-            vessels in the deep papillary dermis, and the neoplastic dense
cording to stages and MF subtypes. During the transition from          cellular infiltrate displaces these vessels in deeper areas [17].



6                                                                           Original Article | Dermatol Pract Concept. 2024;14(1):e2024063
      Table 3. Histopathological features and microvascular density scoring of mycosis fungoides
                               and small plaque parapsoriasis patients.
                                                                 Mycosis fungoides                    Parapsoriasis
                                                                                                                                 P
                                                                  N            %                  N                   %
 CD7 loss                              None                       12         (42.86)              23             (74.19)      0.014
                                       Present                    16         (57.14)              8              (25.81)
 CD30 expression                       None                       28        (100.00)              31            (100.00)      0.999
                                       Present                    0          (0.00)               0              (0.00)
 Spongiosis                            None                       15         (53.57)              8              (25.81)      0.029
                                       Present                    13         (46.43)              23             (74.19)
 Epidermal change                      None                       15         (53.57)              22             (70.97)      0.146
                                       Parakeratosis              8          (28.57)              8              (25.81)
                                       Acanthosis                 5          (17.86)              1              (3.23)
 Lymphocytic infiltration with         None                       2          (7.14)               15             (48.39)      <0.001
 large/irregular nuclei                Minimal                    16         (57.14)              16             (51.61)
                                       Marked                     10         (35.71)              0              (0.00)
 Dermal fibrosis                       None                       6          (21.43)              8              (25.81)      0.541
                                       Minimal                    21         (75.00)              23             (74.19)
                                       Marked                     1          (3.57)               0              (0.00)
 Localization of dermal                Perivascular               9          (32.14)              26             (83.87)      <0.001
 infiltration                          Band                       18         (64.29)              6              (19.35)
                                       Perifollicular             3          (10.71)              0              (0.00)
                                       Peri adnexal               1          (3.57)               0              (0.00)
                                                                            Median                              Median
                                                          Mean± SD        (Min.-Max)        Mean± SD          (Min.-Max)         P
 MVD (highest score area)                                 23.64±9.76       22.5 (9-49)      18.06±8.12          15 (8-42)     0.010
 MVD (sum of three highest score area)                   59.04±24.21      57 (21-119)      43.94±16.77         39 (22-98)     0.007

MVD = microvascular density.



    Structureless orange-colored areas were more frequently            tumoral vascular structures that could not be detected by
observed in MF than in SPP, and they often had a patchy pat-           dermatoscopy [19,20]. In our study, magnification levels that
tern in our study. The two groups did not significantly differ         could not be reached with videodermatoscopy were achieved
in terms of the presence of scale, scale localization, purpuric        with the image clarity offered by lesional capillaroscopy. For
areas, dilated follicle, and structureless white-colored areas.        instance, the distinction between short linear vessels and lin-
The occurrence of purple coloration was significantly higher           ear curved vessels is not always clear with videodermatos-
in the MF patients than in the SPP patients. In other studies,         copy, whereas these vessels can be easily characterized with
patchy structureless orange-colored area is common in MF.              lesional capillaroscopy.
Although a structureless orange-colored area is also found                Lesional capillaroscopy assessment has previously been
in SPP, it is more often diffuse [3,17]. The presence of struc-        applied in several studies to evaluate the response of psori-
tureless orange-colored areas is not specific to CTCL. In a            atic lesions to treatments. In these studies, a magnification of
study involving other nodular or plaque-type T- and B-cell             up to ×300 was used to evaluate the effects of treatment on
primary cutaneous lymphomas, the strongest dermatoscopic               angiogenesis and microcirculation [21-23]. Further studies
predictor for primary cutaneous lymphoma is the structure-             on the use of lesional capillaroscopy in MF patients for prog-
less orange-colored area s[18].                                        nosis or follow-up treatment are thus needed.
    To our best knowledge, there are very few studies on                  Another advantage of dermatoscopy is that clinically sus-
the use of capillaroscopy in neoplastic lesions exist. In these        picious lesions can be marked. In various skin tumors marking
studies, the occurrence of angiogenesis in basal cell carci-           of suspicious areas might increase the rate of d
                                                                                                                      ­ iagnosis [24].
noma was evaluated with videocapillaroscopy. The ad-                   Given that histopathological findings are focal in MF, obtain-
vantage of videocapillaroscopy is that it could detect the             ing biopsy samples from areas where evident findings have



Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                                        7
Figure 2. (A) Parakeratosis in the epidermis, focal subepidermal separation, marked vacuolar degeneration in the spongiotic background,
severe lymphohistiocytic cell infiltration accompanied by band-forming lymphoid cells with large hyperchromatic nuclei (H&E x200).
(B) Atypical lymphoid cells showing hyperchromatic large-nucleated epidermotropism (H&E x400) (arrows). (C) Increased vascularity in
the superficial dermis (CD34 x200). (D) Comparison with a case without mycosis fungoides (CD34 X200).




been obtained through dermoscopy and lesional capillaros-            diagnosis with the loss of CD5 are 65.8% and 72.7%, re-
copy might increase the rate of diagnostic success.                  spectively, and 73.7% and 77.0% for the loss of CD7, re-
    Angiogenesis has prognostic significance in many solid or        spectively [8] .
hematological cancers, and anti- angiogenic agents are used              In terms of dermatoscopic parameters, the respective
in treatments [25,26]. In many different non-Hodgkin lym-            sensitivity and specificity for MF diagnosis were 85.2% and
phoma subtypes, angiogenesis is evaluated through MVD                54.8% in the presence of short linear vessels and 53.0% and
scoring, and it has been found to be associated with progno-         80.0% in the presence of linear, curved vessel. The sensitiv-
sis [27,28]. In a study where angiogenesis and dermatoscopy          ity and specificity of the International Society for Cutane-
findings were evaluated, MVD scores were high in MF pa-              ous Lymphoma (ISCL) diagnostic algorithm are 87.5% and
tients [29]. In another study in which cell proliferation and        60.0%, respectively [31]. Thus, MVD determination and
angiogenesis were measured with Ki-67 and CD31, MVD                  application of dermatoscopic parameters might be practical
was higher in MF than in benign dermatoses. Additionally,            and diagnostically valuable, and further studies on the inte-
angiogenesis is associated with stage [30] .                         gration of these parameters into MF diagnostic algorithms
    In our study, patients with an MVD score of >20 were             are needed.
classified as having MF, with 67.9% sensitivity and 67.7%                Although       SPP   is   considered   a   benign   dermato-
specificity. The reported sensitivity and specificity for MF         sis, its development into MF has been reported in the



8                                                                         Original Article | Dermatol Pract Concept. 2024;14(1):e2024063
Figure 3. (A) Digitate patches on the trunk of a small plaque parapsoriasis (SPP) patient. (B) Oval shaped digitate patches on the back of a
SPP patient. (C) Reddish brown poikilodermic sharply demarcated mycosis fungoides (MF) patches with fine scales. (D) Widespread pink-or-
ange patches of MF on the trunk and extremities.




Table 4. Variation of dermoscopic parameters according to Guitart and microvascular density scores
                        in patients with mycosis fungoides and parapsoriasis.
                                                                  MVD (area with the                   MVD (sum of three
                               Guitart Score                        highest score)                     highest score areas)
                                                        P                                     P                                        P
                                   Median                                  Median                                     Median
                         Mean± SD (Min.-Max)                     Mean± SD (Min.-Max)                 Mean± SD        (Min.-Max)
Short linear    None        4±1.67        4 (1-7)                19.76±8.83    18 (9-40)            47.05±17.34      46 (21-92)
                                                      0.011                                 0.536                                    0.424
vessel          Present 5.13±1.82        5.5 (1-7)               21.24±9.61    21 (8-49)            53.34±23.86 50 (23-119)
Linear        None 4.26±1.87              5 (1-7)                20.39±8.94 18.5 (9-42)             51.29±21.79 48.5 (22-116)
                                                      0.007                                 0.715                                    0.924
curved vessel Present 5.57±1.47           6 (1-7)             21.29±10.11 21 (8-49)                 50.76±22.42 48 (21-119)
Dotted          None      4.52±1.76       5 (1-7)             22.52±10.80 21 (8-49)                 56.24±26.54 52 (22-119)
                                                      0.315                                 0.356                                    0.330
vessel          Present 4.88±1.90         5 (1-7)                19.38±7.92    18 (9-40)            47.32±17.03      42 (21-92)
Branching     None 4.43±1.82              5 (1-7)                18.5±6.93     18 (8-42)            46.5±16.54       44 (21-98)
                                                      0.020                                 0.018                                    0.065
linear vessel Present 5.6±1.64            6 (1-7)                27.2±12.24 24 (12-49)              64.6±29.51       56 (32-119)

MVD = microvascular density; SD = standard deviation.



Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                                             9
                   Table 5. Determination of the cut-off value for mycosis fungoides disease.
                                                                      Asymptomatic
                                                                     95% Confidence
                                                                         interval            Cut-off
                                                Asymptomatic         Lower       Upper
       ROC Model             Area       SD       Significance         Bond       Bond                    Sensitivity     Specificity
 MVD (area with the          0.696     0.069          0.010           0.560       0.831      >20.00        %67.86          %67.70
 highest score)
 MVD (sum of three           0.703     0.068          0.007           0.569       0.837      >51.50        %64.29          %71.00
 highest score area)
 Short linear vessel         0.703     0.069          0.008           0.568       0.838          >0.50     %85.21          %54.80
 Linear curved vessel        0.671     0.072          0.024           0.531       0.812          >0.50     %53.57          %80.60
 Branching linear vessel     0.632     0.074          0.082           0.487       0.776          >0.50     %39.29          %87.10

MVD = microvascular density; ROC = receiver operating characteristic; SD = standard deviation.




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Original Article | Dermatol Pract Concept. 2024;14(1):e2024063                                                                                  11
