10.5826/dpc.1204a198
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2160-9381
2294
en
Iris Zaludek
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Dermatology Practical & Conceptual
dermoscopy
Dermoscopy of lymphoplasmacellular erosive dermatitis of the scalp reveals striking similarities to lymphoplasmacellular balanitis of Zoon
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Research Letter
2022-10-31
2022-01-06
2022-10-31
2022-12-02
e2022198
Dermatol Pract Concept
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Iris Zaludek
2022/10/31
10.5826/dpc.1204a198
e2022198
Dermatology Clinic, Maggiore Hospital, University of Trieste
2160-9381
dermoscopy
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e2022198
Errichetti E. Dermoscopy in general dermatology (non‐neoplastic dermatoses): pitfalls and tips. Int J Dermatol. 2021;60:653–60. DOI: 10.1111/ijd.15427
Dermoscopy of lymphoplasmacellular erosive dermatitis of the scalp reveals striking similarities to lymphoplasmacellular balanitis of Zoon
https://dpcj.org/index.php/dpc/article/download/2294/1786
  Dermoscopy of Lymphoplasmacellular Erosive
Dermatitis of the Scalp Reveals Striking Similarities
    to Lymphoplasmacellular Balanitis of Zoon
   Enrico Zelin1, Claudio Conforti1, Ludovica Toffoli1, Nicola Di Meo1, Diego Signoretto2,
                                       Iris Zalaudek1


1 Dermatology Clinic, Hospital Maggiore, University of Trieste, Trieste, Italy
2 Pathological Anatomy and Histology Department, Cattinara Hospital, University of Trieste, Trieste, Italy



Key words: scalp dermatitis, lymphoplasmacellular dermatitis, erosive dermatitis, dermoscopy
Citation: Zelin E, Conforti C, Toffoli L, Di Meo N, Signoretto D, Zalaudek I. Dermoscopy of lymphoplasmacellular erosive dermatitis
of the scalp reveals striking similarities to lymphoplasmacellular balanitis of Zoon. Dermatol Pract Concept. 2022;12(4):e2022198.
DOI: https://doi.org/10.5826/dpc.1204a198
Accepted: March 14, 2022; Published: October 2022
Copyright: ©2022 Zelin 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: Enrico Zelin, MD, Dermatology Clinic, Hospital Maggiore, Piazza dell’Ospitale 1, 34129, Trieste, Italy. Phone
number: +393476099494, E-mail address: enrico.zelin@gmail.com



Introduction                                                             infiltrate in both reticular and superficial dermis (Figure 2),
                                                                         together with admixed eosinophils, neutrophils and mast
We describe an erosive dermatitis of the scalp characterized             cells and intraepidermal spongiosis. The histopathological
by a prominent inflammatory lymphoplasmacellular infil-                  picture suggested therefore a subacute dermatitis that we
trate and presenting orange structureless areas with linear              called ‘lymphoplasmacellular erosive dermatitis of the scalp’
vessels on dermoscopy.                                                   (LEDS). All patients were treated for 25-30 days with beta-
                                                                         methasone 0.1% and fusidic acid 2% cream (twice daily),
                                                                         obtaining complete response.
Case Presentation
We herein report a case series of 4 male patients, aged
                                                                         Conclusions
77-86 years, presenting non-tender eroded plaques and
crusts on the scalp, persisting for several weeks. They all              Our case series underlines that differential diagnosis of
showed androgenic alopecia and actinic damage, reporting                 eroded lesions and crusts on the scalp can be sometimes
history of actinic keratoses and squamous or basal cell car-             troublesome: neoplastic diseases should be primarily ex-
cinomas. On dermoscopy, the eroded lesions showed red-­                  cluded, but LEDS should be considered among other entities
orange structureless areas with tortuous and telangiectatic              (Table 1) [1,2].
linear vessels, together with white-yellow scales and crusts                  LEDS seems to share many aspects with erosive pustu-
(Figure 1). B
            ­ iopsies were performed and histopathological               lar dermatosis of the scalp (EPDS), such as advanced age,
examination showed a prominent lymphoplasmacellular                      actinic damage, history of previous trauma/surgery [3,4].



Research Letter | Dermatol Pract Concept. 2022;12(4):e2022198                                                                         1
Figure 1. (A-D) Lymphoplasmacellular erosive dermatitis of the scalp: clinical appearance of eroded plaques and crusts. (E) Clinical image
of Zoon balanitis: erythematous lesions on glans penis and prepuce. (F-I) Dermoscopic features of lymphoplasmacellular erosive dermatitis
of the scalp: red-orange structureless areas with tortuous and telangiectatic linear vessels, white-yellow scales and crusts. (L) Dermoscopic
features of Zoon balanitis: red-orange areas with small tortuous linear vessels.




                 Figure 2. Histopathological features of lymphoplasmacellular erosive dermatitis of the scalp.
                 ­(A-B) ­Dermal infiltrate presenting numerous plasma cells, H&E stain, 40x (A) and 63x (B) magnification.




Histopathologically, classical EPDS shows a mixed in-                   conditions, including those characterized by a dense/com-
flammatory infiltrate, with lymphocytes, plasma cells, and              pact cellular infiltrate, causing the so-called ‘mass effect’,
neutrophils, often forming pustules [3]. Instead, a predom-             such as granulomatous dermatoses. Notably, in these cases,
inant lymphoplasmacellular infiltrate is not a classic his-             vessels are usually well-focused as the dermal infiltrate/
topathological feature of EPDS, but biopsy timing as well               deposit pushes them toward the skin surface [7]. Interest-
as local and systemic immunological factors could play a                ingly, the orange hue in Zoon balanitis has been attributed
role in determining this appearance. On dermoscopy, EPDS                to hemosiderin deposits [6], but could also be due to the
shows serum-hematic crusts, loss of follicular ostia and hair           aforementioned ‘mass effect’. In addition, another relevant
tufting, enlargement of dermal vessels and visualization of             similarity between LEDS and Zoon balanitis is the clinical
hair bulbs through a thinned skin [3], milky-red and white              course, with response to topical steroid administration and
areas, linear but also polymorphous vessels [1]. Instead, in            frequent recurrences [4].
our cases we observed a remarkable orange structureless                     In conclusion, while LEDS could be interpreted as a
background with focused linear vessels. Notably, this der-              variant of EPDS, the peculiar dermoscopic findings (orange
moscopic pattern has been linked to the so called idiopathic            structureless areas and linear vessels) apparently related to
lymphoplasmacellular mucositis-dermatitis (ILPMD), a                    distinctive histological features (dense lymphoplasmacellular
group of disorders presenting a dense non-neoplastic plas-              infiltrate) suggest that LEDS may be also categorized within
ma-cell infiltrate of uncertain etiology, that usually affect           the spectrum of chronic idiopathic lymphoplasmacellular
mucosal areas such as genitalia (typified by Zoon balani-               dermatitis. Further investigations on a larger number of
tis/vulvitis) [5,6]. Orange areas can be observed in several            cases are needed to better define this entity.



2                                                                            Research Letter | Dermatol Pract Concept. 2022;12(4):e2022198
   Table 1. Differential diagnoses of entities presenting with eroded lesions and crusts on the scalp:
                          description of dermoscopic features and useful clues.
   Differential diagnosis                  Dermoscopic appearance                             Clues and other features
 Neoplastic diseases (if ulcerated)
 Basal cell carcinoma            Presence of typical signs such as on-focus         Relatively frequent on scalp presenting
                                 arborizing vessels, blue-grey ovoid nests          actinic damage; diagnosis can be more easily
                                 and globules/dots, brown spoke wheel or            assessed focusing on non-ulcerated areas [2]
                                 leaf like areas, ulcerations or erosions, shine
                                 white streaks, structureless white to red
                                 areas [2]
 Squamous cell carcinoma         Red structureless areas with polymorphous          Relatively frequent on scalp presenting
                                 vessels (linear, hairpin or glomerular vessels),   actinic damage; differential diagnosis
                                 ulcerations, white halos surrounding               may be difficult, in particular with poorly
                                 vascular structures, white-yellow to               differentiated squamous cell carcinoma [2]
                                 light brown structureless areas (keratin),
                                 targetoid-appearing hair follicles (white
                                 circles) [2]
 Merkel cell carcinoma           Milky-red and shiny white areas, pink or           Very rapid growth [1]
                                 purple hue, polymorphous vessels (often
                                 linear irregular, dotted, arborizing or
                                 glomerular vessels), ulcerations [1]
 Amelanotic melanoma             Pigment remnants, milky red areas, more         Often shows pigment remnants that can be a
                                 than one shade of pink, white structures,       very useful diagnostic clue [2]
                                 polymorphous vessels (more often linear
                                 irregular and dotted, but also hairpin vessel),
                                 ulcerations [2]
 Atypical fibroxanthoma          Pink-red and white structureless areas, linear     Rapid growth [1]
                                 irregular vessels, white lines, ulcerations [1]
 Inflammatory diseases
 Classic erosive pustular        Crusts, erosions, milky red areas, on-focus        Shares many clinical and dermoscopic
 dermatosis of the scalp         polymorphous vessels, hair tufting, skin           features with lymphoplasmacellular erosive
                                 atrophy (visualization of dermal vessels and       dermatitis of the scalp [1,3]
                                 hair bulbs) [1,3]
 Bullous diseases such as        Erosions and scarring alopecia; acantholytic       Subepidermal blisters (Bursting
 localized cicatricial bullous   hair casts in pemphigus vulgaris [1]               Perry disease) or intraepidermal
 pemphigoid (Brunsting                                                              blisters (pemphigus vulgaris). Direct
 Perry disease) and                                                                 immunofluorescence and circulating
 pemphigus vulgaris                                                                 antibody tests are useful. Pemphigus vulgaris
                                                                                    often involves other body areas [1]
 Severe bacterial or fungal      Perifollicular pustules, purulent discharge;       Painful lesions; microbiological test are
 infection                       hair change in fungal infection (black dots,       useful [1,3]
                                 broken hairs, comma hairs, corkscrew,
                                 zigzag and barcode hairs) [1,3]
 Discoid lupus                   Erythematous patches, scaling, follicular   Direct immunofluorescence shows
 erythematosus                   plugging and arborizing vessels;            immunoglobulin and complement deposition
                                 hyperpigmentation, white areas, atrophy and on skin sample (positive lupus band test).
                                 scarring alopecia in later phases [1,3]
 Folliculitis decalvans          Hair tufting, follicular pustules, scarring        /
                                 alopecia [1,3]
 Neutrophilic dermatoses         Flaccid pustules and vesicles, erosions [3]        Usual localization is trunk and main folds,
 such as sub-corneal                                                                scalp is rarely involved [3]
 pustular dermatosis
 Pyoderma gangrenosum            No specific dermoscopic features; clinically       Painful lesions; histopathology can show
                                 ulcer with undermined borders [1,3]                neutrophilic infiltrate; scalp localization is
                                                                                    infrequent [1,3]




Research Letter | Dermatol Pract Concept. 2022;12(4):e2022198                                                                        3
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