10.5826/dpc.1401a22
text/xml
2160-9381
3495
en
Manjit Kaur Rana
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
seronegative
Dermoscopy in Necrolytic Acral Erythema: A Case Report 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2024-01-31
2023-05-02
2024-01-31
2024-02-21
e2024022
Dermatol Pract Concept
Manjit Kaur Rana
2024/01/31
10.5826/dpc.1401a22
e2024022
Department of Pathology, AIIMS, Bathinda, India
2160-9381
seronegative
en
e2024022
Bentley D, Andea A, Holzer A, Elewski B. Lack of classic histology should not prevent diagnosis of necrolytic acral erythema. J Am Acad Dermatol. 2009;60(3):504–507. DOI: 10.1016/j.jaad.2008.08.046. PMID: 18992966. PMCID: PMC2708073.
Dermoscopy in Necrolytic Acral Erythema: A Case Report 
https://dpcj.org/index.php/dpc/article/download/3495/2452
             Dermoscopy in Necrolytic Acral Erythema:
                         A Case Report
                 Shivani Bansal1, Parul Chojer1, Sushama Sushama1, Manjit Kaur Rana2


1 Department of dermatology, AIIMS, Bathinda, India
2 Department of Pathology, AIIMS, Bathinda, India



Key words: necrolytic, acral, erythema, dermoscopy, seronegative,
Citation: Bansal S, Chojer P, Sushama S, Rana MK. Dermoscopy in Necrolytic Acral Erythema: A Case Report. Dermatol Pract Concept.
2024;14(1):e2024022. DOI: https://doi.org/10.5826/dpc.1401a22
Accepted: August 1, 2023; Published: January 2024
Copyright: ©2024 Bansal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non
Commercial 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 Sushama, Department of dermatology, AIIMS, Bathinda, Dabwali road, India. Phone numbers: +919958719382
Email address: singh.sushama@gmail.com




Introduction                                                             mode) of the acute lesions revealed multiple perifollicular
                                                                         white globules on intense red- violaceous background inter-
    Necrolytic acral erythema (NAE) is characterized by                  spersed with short linear vessels (Figure 2A). Dermoscopy of
­erythema, blisters or erosion in the acute stage to well-defined,       the ulcer showed yellow globules with radial white striations
hyperkeratotic plaques on the dorsum of feet and toes in the             surrounded by brown dots and patches in polarized mode
chronic stage [1]. We present a dermoscopy of a case of NAE              and dirty yellow scales and white globules in non-polarized
which may help in the diagnosis.                                         mode (Figure 2, B and C). Raw areas revealed uniformly dis-
                                                                         tributed red dots and globules with peripheral white scales

Case Presentation                                                        in polarized dermoscopy (Figure 2, D and E). Dermoscopy of
                                                                         chronic hyperkeratotic hyperpigmented plaques presented a
A 32-year-old female presented with hyperpigmented                       mixture of gray-brown pigmentation along with dirty white
plaques on the dorsum of her feet, predominantly on the                  scales and red globules (Figure 2F). Few resolved areas reveal
medial aspect (Figure 1A). Erythematous macules, plaques                 whitish striations in a branching pattern with brown patches
                                                      2          2
of irregular shape and size varying from 0.5 cm to 4 cm in               and linear red vessels on a white background (Figure 2,
diameter were present on bilateral lower legs interspersed               G and H).
with follicular or non-follicular pustules, erosions and ulcers               Her viral markers were non-reactive and patch test with
superimposed with yellowish crust (Figure 1B). Differential              Indian standard and footwear series was negative. However,
diagnosis of allergic contact dermatitis, psoriasis, pellagra            serum albumin and serum zinc level were borderline low.
and necrolytic acral erythema was kept. Dermoscopic ex-                  Skin biopsy from the hyperkeratotic plaque revealed psori-
amination (Illuco IDS 1100, 10x magnification, polarized                 asiform dermatitis (Figure 2I). She was prescribed a tablet




Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022                                                                        1
                                                                        zinc acetate 100 mg three times a day for 3 months to which
                                                                        the erythematous lesions, ulceration and edema responded
                                                                        well in 2 weeks. Topical super potent steroid was given for
                                                                        the hyperkeratotic lesions. There is no relapse at 3 months
                                                                        follow-up (Figure 2J). The clinical, dermoscopic and histo-
                                                                        pathologic findings along with supportive investigations and
                                                                        substantial improvement with oral zinc supplementation
                                                                        confirmed our diagnosis of NAE.


                                                                        Conclusions
                                                                        Although NAE has been associated with HCV infection,
                                                                        there have been few HCV seronegative case reports [2,3].
                                                                        Our patient was also seronegative for HCV infection.
                                                                        Clinically, patients with NAE are systemically well and
                                                                        have a typical acral distribution which helps in ruling out
                                                                        causes of other acral erythemas such as pellagra, biotin
                                                                        and fatty acid deficiency [1]. Chronic lesions of NAE have
                                                                        to be differentiated from psoriasis, hyperkeratotic eczema
Figure 1. (A) Clinical image of a 32-year-old seronegative female       and hypertrophic lichen planus. Our findings of dermos-
of necrolytic acral erythema showing bilaterally symmetrical hyper-
                                                                        copy of the lesions may assist in diagnosing both acute
pigmented verrucous plaques present over dorsum of legs and feet.
(B) Clinical image of acute lesions of the patient showing erythem-
                                                                        and chronic manifestations of NAE (Table 1). We could
atous macules and plaques of irregular shape and sizes with ulcers      find only a single study on dermoscopy of necrolytic acral
and erosions interspersed with pustulation.                             erythema [1].




Figure 2. (A) Dermoscopy (polarized) showing multiple perifollicular white globules (black arrow) on intense red- violaceous background
(brown arrow) interspersed with white structureless areas (green star) and short linear vessels (blue arrow). (B) Polarized dermoscopy of
ulcer shows yellow globules (black arrow) with radial white striations (brown arrow) surrounded by brown dots and patches (blue arrow).
(C) Dermoscopy on non-polarized mode reveals white globule (black arrow) and dirty yellow crust (brown arrow) suggestive of dried serum
on red background. (D) Dermoscopic examination reveal red background (brown star) with uniform red dots (blue arrow), few red globules
(green arrow) and peripheral dirty white scales (gray arrow) and brown patches (purple arrow). (E) Dermoscopy on polarized mode, red dots
in uniform pattern (black arrow) can be better appreciated with whitish scales (brown arrow). (F) Dermoscopy of chronic hyperkeratotic
hyperpigmented plaques presented mixture of gray brown pigmentation (black arrow) along with dirty white scales (brown arrow) and red
globules (blue arrow). (G) Resolved areas reveal whitish striations in a branching pattern (black arrow) with brown patches (blue star) on
dermoscopy. (H) Linear vessels (black arrow) on white background (blue star) and whitish striations (red arrow) on dermoscopic examina-
tion of these resolved areas. (I) Histopathology of the section shows mild hyperkeratosis, regular acanthosis in epidermis, numerous dilated
capillaries in dermal papilla along with mild perivascular inflammatory infiltrate composed of lymphocytes and histiocytes (H&E stain;
40X). (J) Clinical image of the patient shows resolution of acute and chronic lesions at 4 months follow-up.




2                                                                           Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022
        Table 1. Clinical-dermoscopic-histopathological correlation of a 32-year-old seronegative
                              female patient of necrolytic acral erythema.
 Stage of
  lesions            Clinical features               Dermoscopic findings         Corresponding histopathological features
 Acute       Erythematous macules and             Red background and             Dilated capillary loops in regularly elongated
 lesions     plaques with                         Uniform Red dots               dermal papillae
             Peri-lesional hyperpigmentation
                                                  Brown dots and patches         Epidermal melanin
             Ulcers with yellowish crust          White perifollicular globules Neutrophil collection, suggestive of acute
                                                                                infection over lesions
                                                  Yellow globules                Dried serous fluid
 Chronic     Hyperkeratotic plaques               Dirty white scales loosely     Hyperkeratosis
 lesions                                          adherent scales
             Hyperpigmented plaques               Brown dots and patches         Epidermal melanin
                                                  Red globules                   Haemorrhages
 Resolved    Whitish to violaceous lesions        Radial whitish striations      Dermal fibrosis
 lesions


   One should have a good suspicion of NAE even if                  2. Pandit VS, Inamadar AC, Palit A. Seronegative necrolytic acral
the ­
    patient is seronegative for HCV and has innocuous-                 erythema: A report of two cases and literature review. Indian
                                                                       Dermatol Online J. 2016;7(4):304-307. DOI: 10.4103/2229
appearing psoriasiform or eczematous lesions with normal
                                                                       -5178.185464. PMID: 27559510; PMCID: PMC4976414.
serum zinc levels. Dermoscopy may be of great assistance for
                                                                    3. Das A, Kumar P, Gharami RC. Necrolytic acral erythema in
the same, however, more studies on dermoscopic findings of             the absence of hepatitis C virus infection. Indian J Dermatol.
this disease need to be done.                                          2016;61(1):96-99. DOI: 10.4103/0019-5154.174047. PMID:
                                                                       26955109. PMCID: PMC4763711.
                                                                    4. Bentley D, Andea A, Holzer A, Elewski B. Lack of classic histol-
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Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022                                                                        3
