10.5826/dpc.1202a69
text/xml
2160-9381
1869
en
Nadia Shirazi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
four dots sign
Rosette/ four dot sign in dermoscopy: A non-specific observation
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-07-06
2022-05-02
2022-05-24
e2022069
Dermatol Pract Concept
Nadia Shirazi
2022/05/02
10.5826/dpc.1202a69
e2022069
Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
2160-9381
four dots sign
en
e2022069
Rosette/ four dot sign in dermoscopy: A non-specific observation
https://dpcj.org/index.php/dpc/article/download/1869/1596
             Rosette or Four Dot Signs in Dermoscopy:
                    a Non-specific Observation
                                  Rashmi Jindal1, Payal Chauhan1, Nadia Shirazi2


1 Department of Dermatology, Venereology & Leprosy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University,
  Dehradun, Uttarakhand, India
2 Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India



Key words: dermoscopy, four dot, actinic keratosis, lichen planus, perniosis, lichen sclerosus et atrophicus
Citation: Jindal R, Chauhan P, Shirazi N. Rosette/ four dot sign in dermoscopy: A non-specific observation.
Dermatol Pract Concept. 2022;12(2):e2022069. DOI: https://doi.org/10.5826/dpc.1202a69
Accepted: October 6, 2021; Published: April 2022
Copyright: ©2022 Jindal 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: Dr Rashmi Jindal, Professor, Department of Dermatology, Venereology & Leprosy, Himalayan Institute of Medical
Sciences, Swami Ram Nagar, Doiwala, Dehradun, Uttarakhand, India. E-mail: rashmijindal98@gmail.com




Introduction                                                             Case Presentation
Rosettes or four dot signs in dermoscopy are described as 4              The present case series describes 5 diseases (in 5 patients)
bright white dots or globules grouped like a four-leaf clover.           where rosettes were seen, suggesting that they would be
They vary in size from 0.2 mm to 0.5 mm and can be ori-                  non-specific. These were lichen sclerosus, lichen planus, per-
ented in the same angulation or different angulation. These              niosis, apocrine hidrocystoma, and photo contact dermatitis
have been characteristically described in squamous cell car-             (Figures 1-5). Diagnoses were confirmed histopathologically,
cinoma and actinic keratosis [1]. However, there have been               and a possible dermoscopy correlation with observed histo-
anecdotal reports of their presence in melanoma, basal cell              pathology was established (Table 1).
carcinoma, dermatofibroma, molluscum contagiosum, lichen
planus like keratosis, discoid lupus erythematosus, and pig-
                                                                         Conclusions
mented purpuric dermatoses [2]. Their definite histopatho-
logical correlate has not been elucidated. The explanation               Rosette sign in dermoscopy is not disease-specific as was once
accepted by most clinicians is that they represent the opti-             presumed. Although it is observed in high frequency in actinic
cal effect between polarized light and follicular structures.            tumors like actinic keratosis and squamous cell carcinoma,
­Polarizing horny material at the infundibular level in ad-              several unrelated inflammatory and papulosquamous diseases
nexal openings and peri-follicular fibrosis results in smaller           also exhibit it. Its most likely explanation is the interaction of
and larger rosettes, respectively.                                       keratin filled adnexal openings with the polarized light.




Research Letter | Dermatol Pract Concept. 2022;12(2):e2022069                                                                            1
Figure 1. (A) Multiple white rosettes (blue circle, Dermlite DL200 hybrid, 10x magnification [3Gen]. (B) Multiple white atrophic plaques
over leg. (C) Hyperkeratosis, epidermal atrophy with basal vacuolar degeneration, papillary dermal edema and underlying lymphocytic
infiltrate (H&E, ×10).




Figure 2. (A) Multiple white rosettes (blue circle). (B) Erythematous to violaceous plaques over trunk and extremities. (C) Hyperkeratosis
with keratin filled craters, basal vacuolar degeneration and dense band like lymphocytic infiltrate at dermo-epidermal junction (H&E, ×10).




Figure 3. (A) White rosettes (blue circle). (B) Erythema and edema over toes. (C) Hyperkeratosis, follicular plugging, dermal edema and
perivascular as well as peri-eccrine lymphocytic infiltrate (H&E, ×10).



2                                                                           Research Letter | Dermatol Pract Concept. 2022;12(2):e2022069
Figure 4. (A) Multiple white rosettes (blue circle). (B) Skin colored to bluish nodules coalescing to form a plaque over the neck.
(C) ­Hyperkeratosis, follicular plugging with peri-follicular fibrosis, multiple dermal cystic spaces lined by a bilaminar epithelium with
­apocrine snouts at places (H&E, ×10).




Figure 5. (A) White rosettes (blue circle). (B) Bright red plaques over dorsae of hands. (C) Parakeatosis with follicular plugging, spongiosis,
dermal edema and peri-vascular lymphocytic infiltrate (H&E, ×10).


Table 1. Demographic profile, clinical features, and dermoscopy-histopathology correlation in 5 cases
                                           with rosette sign.
  Figure      Age (years)/                                                     Histopathological        Dermoscopy correlation with
 (Case) #       Gender             Clinical presentation          Duration         diagnosis             histopathology for rosettes
 #1          18/male            Multiple white atrophic           2 years      Lichen sclerosus et      Follicular plugging
                                plaques over left leg                          atrophicus
 #2          22/ female         Multiple, itchy                   2 months     Lichen planus            Hyperkeratosis with sharp
                                erythematous to                                                         depressions giving the
                                violaceous plaques over                                                 appearance of keratin filled
                                trunk and extremities                                                   craters
 #3          20/ female         Erythema and edema over           4 days       Perniosis                Hyperkeratosis with wavy
                                toes                                                                    margin and peri-eccrine
                                                                                                        inflammation
 #4          30/ male           Skin-colored to bluish            10 years     Apocrine                 Hyperkeratosis with follicular
                                nodules coalescing to form                     hidrocystoma             plugging and peri-follicular
                                a plaque over the neck                                                  fibrosis
 #5          60/ male           Bright red plaques over           7 days       Photo-contact            Parakeratotis scale filling the
                                dorsae of hands                                dermatitis               sweat duct openings.



Research Letter | Dermatol Pract Concept. 2022;12(2):e2022069                                                                                3
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