10.5826/dpc.1304S1a309S
Dermoscopy has been showed to facilitate the non-invasive recognition of several infectious disorders (infectiouscopy) thanks to the detection of peculiar clues. Although most of the knowledge on this topic comes from studies involving light-skinned patients, there is growing evidence about its use also in dark phototypes. This systematic literature review summarizes published data on dermoscopy of parasitic, bacterial, viral and fungal dermatoses (dermoscopic findings, used setting, pathological correlation, and level of evidence of studies) and provides a homogeneous terminology of reported dermoscopic features according to a standardized methodology. A total of 66 papers addressing 41 different dermatoses (14 bacterial, 5 viral, 11 fungal infections, and 11 parasitoses/bites and stings) and involving a total of 1096 instances were included in the analysis. The majority of them displayed a level of evidence of V (44 single case reports and 21 case series), with only 1 study showing a level of evidence of IV (case-control analysis). Moreover, our analysis also highlighted a high variability in the terminology used in the retrieved studies. Thus, although promising, further studies designed according to a systematic and standardized approach are needed for better characterization of dermoscopy of infectious skin infections.
text/xml
2160-9381
3538
en
Enzo Errichetti
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
systematic review
Dermoscopy of Infectious Dermatoses (Infectiouscopy) in Skin of Color—A Systematic Review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-04
2023-05-13
2023-10-04
2023-11-27
e2023309S
Dermatol Pract Concept
Dermoscopy has been showed to facilitate the non-invasive recognition of several infectious disorders (infectiouscopy) thanks to the detection of peculiar clues. Although most of the knowledge on this topic comes from studies involving light-skinned patients, there is growing evidence about its use also in dark phototypes. This systematic literature review summarizes published data on dermoscopy of parasitic, bacterial, viral and fungal dermatoses (dermoscopic findings, used setting, pathological correlation, and level of evidence of studies) and provides a homogeneous terminology of reported dermoscopic features according to a standardized methodology. A total of 66 papers addressing 41 different dermatoses (14 bacterial, 5 viral, 11 fungal infections, and 11 parasitoses/bites and stings) and involving a total of 1096 instances were included in the analysis. The majority of them displayed a level of evidence of V (44 single case reports and 21 case series), with only 1 study showing a level of evidence of IV (case-control analysis). Moreover, our analysis also highlighted a high variability in the terminology used in the retrieved studies. Thus, although promising, further studies designed according to a systematic and standardized approach are needed for better characterization of dermoscopy of infectious skin infections.
Enzo Errichetti
2023/10/04
10.5826/dpc.1304S1a309S
e2023309S
University of Udine, Italy
2160-9381
systematic review
en
e2023309S
Vinay K, Handa S, Khurana S, Agrawal S, De D. Dermatoscopy in Diagnosis of Cutaneous Myiasis Arising in Pemphigus Vulgaris Lesions. Indian J Dermatol. 2017;62:440.
Dermoscopy of Infectious Dermatoses (Infectiouscopy) in Skin of Color—A Systematic Review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force
https://dpcj.org/index.php/dpc/article/download/3538/2347
          Dermoscopy of Infectious Dermatoses
     (Infectiouscopy) in Skin of Color – A Systematic
    Review by the International Dermoscopy Society
          “Imaging in Skin of Color” Task Force
    Payal Chauhan1, Biswanath Behera2, Delaney D Ding3, Aimilios Lallas4, Soumil Khare5,
       Nkechi Anne Enechukwu6, Martyna Sławińska7, Bengu Nisa Akay8, Balachandra
        S Ankad9, Yasmeen J Bhat10, Abhijeet Kumar Jha11, Feroze Kaliyadan12, Awatef
      Kelati13, Shekhar Neema14, Nisha V Parmar15, Jennifer Stein16, Richard P Usatine17,
                          Keshavamurthy Vinay18, Enzo Errichetti19


 1 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India
 2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India
 3 University of Florida College of Medicine, Gainesville, FL, USA
 4 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
 5 Department of Dermatology, Venereology and Leprosy, AIIMS, Raipur, India
 6 Nnamdi Azikiwe University/Nnamdi Azikiwe Teaching Hospital Nnewi, Anambra State, Nigeria
 7 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
 8 Department of Dermatology, School of Medicine, Ankara University, Ankara, Turkey
 9 Department of Dermatology, Venereology and Leprosy, SN Medical College, Bagalkot, Karnataka, India
10 Department of Dermatology, Venereology and Leprology, Government Medical College, University of Kashmir, Srinagar, Jammu and
   Kashmir, India
11 Department of Dermatology & STD, Patna Medical College & Hospital, Patna, India
12 Department of Dermatology, Sree Narayana Institute of Medical Sciences, Ernakulum, India
13 Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS),
   Casablanca, Morocco
14 Department of Dermatology, Venereology and Leprology, Armed Force Medical College, Pune, Maharashtra, India
15 Department of Dermatology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
16 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
17 Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health
   San Antonio, San Antonio, TX, USA
18 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
19 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy



Key words: dermoscopy, dermatoscopy, entodermoscopy, entomodermoscopy, epiluminescence, infections, skin of color, dark skin, black
skin, ethnic skin, dark phototype, african skin, systematic review
Citation: Chauhan P, Behera B, Ding DD, et al. Dermoscopy of Infectious Dermatoses (Infectiouscopy) in Skin of Color – a systematic
review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force. Dermatol Pract Concept. 2023;13(4)
S1:e2023309S. DOI: https://doi.org/10.5826/dpc.1304S1a309S
Accepted: September 26, 2023; Published: October 2023
Copyright: ©2023 Chauhan 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.




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S                                                                                1
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Enzo Errichetti, MD, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy.
Email: enzoerri@yahoo.it




    ABSTRACT           Dermoscopy has been showed to facilitate the non-invasive recognition of several infectious disorders
                       (infectiouscopy) thanks to the detection of peculiar clues. Although most of the knowledge on this
                       topic comes from studies involving light-skinned patients, there is growing evidence about its use
                       also in dark phototypes. This systematic literature review summarizes published data on dermoscopy
                       of parasitic, bacterial, viral and fungal dermatoses (dermoscopic findings, used setting, pathological
                       correlation, and level of evidence of studies) and provides a homogeneous terminology of reported
                       dermoscopic features according to a standardized methodology. A total of 66 papers addressing 41
                       different dermatoses (14 bacterial, 5 viral, 11 fungal infections, and 11 parasitoses/bites and stings)
                       and involving a total of 1096 instances were included in the analysis. The majority of them displayed
                       a level of evidence of V (44 single case reports and 21 case series), with only 1 study showing a level of
                       evidence of IV (case-control analysis). Moreover, our analysis also highlighted a high variability in the
                       terminology used in the retrieved studies. Thus, although promising, further studies designed accord-
                       ing to a systematic and standardized approach are needed for better characterization of dermoscopy
                       of infectious skin infections.




Introduction                                                             the PubMed electronic database using the following search
                                                                         terms: “dermoscopy” OR “epiluminescence” OR “derma-
The group of infectious skin disorders encompass a wide                  toscopy” AND “skin of color” OR “dark skin” OR “black
number of conditions due to parasitic, bacterial, viral and              skin” OR “ethnic skin” OR “dark phototype” OR “african
fungal agents [1-3]. Whereas the use of dermoscopy was                   skin” OR “indian skin”. Titles and abstracts were screened
initially conceived for parasitoses and insect bites/stings,             by two independent reviewers to identify papers reporting
there has been a significant increase of publication also on             dermoscopic findings of skin infestations, insect bites/stings,
non-parasitic cutaneous infections [3]. Thanks to the detec-             bacterial, viral and fungal skin infections; articles dealing
tion of peculiar clues, dermoscopic assessment may help the              with hair, nail, and mucosal conditions were not considered
clinician promptly recognize some infectious dermatoses                  and non-English articles, reviews, personal opinions/editori-
without the use of time-consuming and expensive investi-                 als and duplicates were excluded. A manual search was also
gations (e.g., microbiological, laboratory, or imaging tests)            performed by assessing the reference sections of all signifi-
[1-3]. Of note, most of studies dealing with dermoscopy of               cant studies or reviews on this topic.
infectious dermatoses involved light-skinned patients [1-3],                  Articles deemed not relevant and those not mentioning
yet there is a growing trend in publications focusing on dark            dermoscopic structures according to specific dermatosis/
phototypes (Fitzpatrick’s phototypes IV-VI) [3,4].                       number of patients with particular dermoscopic structures
    This systematic review, performed on behalf of the Inter-            were excluded after full-text reading. Only articles specif-
national Dermoscopy Society (IDS) Task Force on “Imaging                 ically dealing with Fitzpatrick’s phototypes IV-VI were in-
in Skin of Color”, aimed at providing for the first time an              cluded. In case information on the skin phototype was not
up-to-date systematic analysis on dermoscopy of infectious               provided, decision on inclusion was made based on a title/
dermatoses (infectiouscopy) in skin of color, also trying to             abstract/full text showing that the manuscript concerned
align dermoscopic terminology of reported ﬁndings follow-                “dark skin” or “skin of color” and for single cases also based
ing a homogeneous standardized nomenclature.                             on the attached figures. We also included papers from Afri-
                                                                         can, Indian subcontinent, and Caribbean countries as most
                                                                         of patients from these areas feature IV-VI skin phototype.
Methods
                                                                         Notably, studies grouping light and dark phototypes without
This systematic review was performed in accordance with                  dedicated subanalyses were excluded.
the PRISMA (Preferred Reporting Items for Systematic Re-                      All of the retrieved studies were classified based on stan-
views and MetaAnalyses) guidelines. A search of the arti-                dard definitions for diagnostic accuracy studies [5,6] and
cles published up to 30th June 2022 was performed through                their level of evidence was assigned according to The Oxford


2                                                                                 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
2011 Levels of Evidence [7]. Dermoscopic findings, histo-             magnification; 4: x16 magnification; 5: x20 magnification;
pathological background (if available), dermoscopic setting           4: x50 magnification; 2: x200 magnification; 3: variable
(polarized vs non-polarized/magnification degree), skin type          magnification), and dermoscopic-pathological correlation
of the patient (if specified), and number of cases were as-           in 33/66 records. Supplemental Table summarizes all such
sessed and summarized. Additionally, standardized terminol-           data, along with analytical description of each of the study
ogy based on the IDS dermoscopic criteria for non-neoplastic          evaluated in the review (number of patients, type of study
dermatoses validated for skin of color was specified for each         and level of evidence), dermoscopic features, skin phototype,
dermoscopic finding reported in the literature [8].                   and corresponding terminology according to the IDS der-
                                                                      moscopic criteria for non-neoplastic dermatoses validated
                                                                      for skin of color. ­Table 1 also shows the general prevalence
Results                                                               (calculated from all data reported in the literature) of dermo-
The initial PubMed search showed 1287 publications,                   scopic findings of included conditions for which a standard-
whereas 49 were added following additional reference                  ized terminology was available. Relevant findings for each
screening, with a total of 82 items admitted to the full-text         dermatosis are reported as follows; for practical purpose,
reading after title and abstract screening and excluding du-          we have grouped them according to the etiological agent.
plicates. Of these, 16 papers were ruled out based on the             ­Figures 2-6 show dermoscopic clues of such conditions.
exclusion criteria, with 66 articles being eventually in the
review process. The flow chart showing the study selection            Bacterial Infections
procedure in depicted in Figure 1.                                    Leprosy
   The full-text review included 44 single case-reports, 21           Leprosy is the bacterial disease with the greatest amount of
case-series, and one case-control study, with the last one be-        data about the use of dermoscopy for diagnostic purposes,
ing the only analysis with a higher level of evidence (IV),           with a total of 12 published studies (1 case-control analysis,
while the rest of the studies had the lowest level of evidence        6 case-series, and 5 single case-reports) [9-20]. Dermoscopic
(V). Forty-one different dermatoses (also accounting for rele-        patterns of the entire spectrum of leprosy has been described
vant disease variants with clinical/dermoscopic peculiarities)        in skin of color, with the commonest findings (reported in
were analyzed, including 14 bacterial, 5 viral, 11 fungal in-         all subtypes) including yellow/yellowish-orange areas, pau-
fections, and 11 parasitoses/bites and stings; a total of 1096        city of appendageal structures (eccrine dots and hairs), and
instances were retrieved. Table 1 shows the number of stud-           vessels (mainly linear vessels with branches) [9-20]. Addi-
ies and total number of included patients for each condition.         tionally, Ankad et al found white structureless areas to be
   Dermoscopic setting (polarized vs non-polarized)                   another frequent feature in borderline tuberculoid leprosy
was reported in 46/66 records (40 polarized; 1 non-­                  in a cohort of 12 patients [11]. Reduced pigment network
polarized; 5 both), magnification in 49/66 records (31: x10           was also observed in all subtypes, apart from lepromatous




         Figure 1. PRISMA flowchart displaying the selection process for study inclusion in the systematic review.


Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S                                                                            3
4
                                                                      Table 1. Total Number of Studies, Instances and of Standardized Dermoscopic Findings of Infectious Dermatoses in Skin of Color.
                                                                                              Total Number
                                                                                               of Instances
                                                                                                (Instances
                                                                                     Total         With
                                                                                    Number     Dermoscopy
                                                                                      of        Prevalence
                                                                Dermatoses          Studies        Data)                                              Dermoscopic Findings* (Total Prevalence)**

                                                          Bacterial infections

                                                          Leprosy
                                                           Borderline tuberculoid     4          63 (12)      Common findings: White structureless areas (100%); Yellow globules (67%); Reduction of eccrine gland openings (50%)
                                                                                                              Less common findings: Linear vessels with branches (33%)
                                                           Tuberculoid                2           6 (0)       -

                                                           Borderline lepromatous     2          27 (0)       -

                                                           Lepromatous                5          35 (2)       Common findings: Peripheral linear vessels with branches (100%); Yellow structureless areas (50%); Orange/brown globules (50%)
                                                                                                              Less common findings: -

                                                           Type 1 reaction            4          34 (14)      Common findings: Vessels: linear with branches (71%); Orange structureless areas (57%)
                                                                                                              Less common findings: Yellow-orange structureless areas (43%); Vessels: linear (29%)

                                                           Type 2 reaction            4          23 (1)       Common findings: Brown dots and globules (100%)
                                                                                                              Less common findings: -

                                                                                      5          12 (6)       Common findings: Vessels: linear with branches (83%); Yellow/orange structureless areas (67%)
                                                           Histoid leprosy
                                                                                                              Less common findings: White scales (33%); Follicular plugs (33%); White structureless areas (17%); Vessels: linear curved
                                                                                                              (17%); White-yellow structureless areas (17%); Peripheral brown structureless areas (17%); Peripheral linear vessels with
                                                                                                              branches (17%)

                                                           Hypopigmented leprosy      1          11 (11)      Common findings: Reduction of skin appendages (82%); White structureless areas (73%); Brown lines, brown reticular lines (73%)
                                                                                                              Less common findings: Perifollicular white color (36%)

                                                           Leprosy (non-specified     1          13 (13)      Common findings: Structureless areas: focal white (92%); Reduction of skin appendages (85%)
                                                          variants)                                           Less common findings: Scales: white patchy (46%); Vessels: linear with branches (31%);
                                                                                                              Brown dots (31%); Structureless areas: orange (23%); Lines: brown (23%); Vessels: linear
                                                                                                              (23%); Vessels: dotted (15%); Structureless areas: brown (8%); Vessels: linear curved
                                                                                                              (8%); Lines: white (8%); Brown globules (8%)
                                                          Lichen scrofulosorum        2           3 (3)       Common findings: Perifollicular white colour (100%); Follicular plug (67%); Peripheral white scales (67%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
                                                                                                              Less common findings: Diffuse white scales (33%); Perifollicular hyperpigmentation (33%)
                                                                                              Total Number
                                                                                               of Instances
                                                                                                (Instances
                                                                                     Total         With
                                                                                    Number     Dermoscopy
                                                                                      of        Prevalence
                                                                Dermatoses          Studies        Data)                                              Dermoscopic Findings* (Total Prevalence)**
                                                          Lupus vulgaris              2          31 (31)      Common findings: Linear vessels (77%); Dotted vessels (71%); Yellow/white globules (61%); White structureless areas (61%);
                                                                                                              Scales: white, yellow (61%)
                                                                                                              Less common findings: White lines (39%); Structureless areas: bright white focal (36%)
                                                                                                              Scales: white patchy (26%); Structureless areas: orange focal (23%); Yellow scales/crusts (19%); Follicular plugs (16%);
                                                                                                              Structureless areas: brown focal (13%); Globules: white (13%), brown (13%); Vessels: linear with branches (10%); Brown dots
                                                                                                              (10%); Lines: brown (10%); White circles (10%); Blue structureless areas (6%); Vessels: linear curved (3%)
                                                          Syphilis (secondary)        1           1 (1)       Common findings: White scales (100%); Peripheral scales (100%); Orange structureless area (100%)
                                                                                                              Less common findings: -
                                                          Trichomycosis axillaris     1           1 (1)       Common findings: Yellow concretions around hair shafts (100%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
                                                                                                              Less common findings: -
                                                          Tuberculosis verrucosa      1           1 (1)       Common findings: Yellow structureless area (diffuse) (100%); White scales (100%); Yellow/orange globules and structureless
                                                          cutis                                               areas (100%)
                                                                                                              Less common findings: -

                                                          Viral infections

                                                          Molluscum contagiosum       4          32 (12)      Common findings: White globules (83%)
                                                                                                              Less common findings: Vessels: peripheral dotted (42%); Linear vessels with branches, peripheral (33%); White to yellow focal
                                                                                                              structureless area (8%); Peripheral linear vessels with branches and dotted vessels (8%)
                                                          Warts
                                                           Plane warts                2          12 (12)      Common findings: Brown structureless area (diffuse) (83%); Dotted vessels (83%)
                                                                                                              Less common findings: Brown dots over a white background (17%); Interruption of skin markings (17%)
                                                           Palmoplantar warts         4         197 (151)     Common findings: Interruption of skin markings (100%); Dotted vessels (52%); Papillae (47%); Yellow, brown structureless
                                                                                                              area (diffuse) (39%)
                                                                                                              Less common findings: Purple dots (13%); Linear vessels (13%)
                                                           Common warts               4         123 (123)     Common findings: -
                                                                                                              Less common findings: Papillae (34%); Brown dots (24%); Dotted vessels (19%); Brown structureless area (diffuse) (17%);
                                                                                                              Dotted or curved linear vessels (11%); Vessels:
                                                                                                              thrombosed (11%); Purple dots (11%); Yellow structureless area (9%); Interruption of skin markings (7%); White structureless
                                                                                                              area (7%); Blue structureless area (4%); Linear vessels (3%); Linear curved vessels (2%)
                                                           Genital warts




5
                                                                                      1           2 (2)       Common findings: Vessels: dotted (100%), linear (50%); Blue structureless area (diffuse) (50%)
                                                                                                              Less common findings: -


                                                                                                                                                                                                                             Table1 continues
                                                               Table 1. Total Number of Studies, Instances and of Standardized Dermoscopic Findings of Infectious Dermatoses in Skin of Color. (continued)




6
                                                                                                Total Number
                                                                                                 of Instances
                                                                                                  (Instances
                                                                                       Total         With
                                                                                      Number     Dermoscopy
                                                                                        of        Prevalence
                                                                Dermatoses            Studies        Data)                                              Dermoscopic Findings* (Total Prevalence)**

                                                          Fungal infections

                                                          Chromoblastomycosis           4           4 (4)       Common findings: Yellow-orange structureless areas (50%); White scales (50%); Yellow crusts (50%); White lines (50%)
                                                                                                                Less common findings: Yellow scales (25%); Dotted vessels (25%); Linear-curved vessels (25%); Brown dots/globules (25%);
                                                                                                                Yellow structureless areas (25%); White structureless areas (25%)
                                                          Mycetoma                      3           3 (3)       Common findings: White scales (67%)
                                                                                                                Less common findings: Yellow globules (33%); White structureless areas (33%); Dotted vessels (33%); Yellow structureless areas
                                                                                                                (33%); Brown/white globules (33%); Small black grains (33%); Blue-white structureless areas (33%)
                                                          Pityriasis versicolor
                                                           Hypopigmented                3         199 (199)     Common findings: -
                                                                                                                Less common findings: White scales: patchy (48%); White scales: in skin furrows (24%); White scales: perifollicular (10%);
                                                                                                                White scales (10%); White scales: diffuse (7%); Vessels: linear branching (7%); White scales: patchy in skin furrows (5%); White
                                                                                                                scales:
                                                                                                                peripheral (5%); Perifollicular white color (3%); Vessels: dotted (2%)

                                                           Hyperpigmented               3          54 (54)      Common findings: White scales (63%)
                                                                                                                Less common findings: Scales (28%): white diffuse/patchy (26%); Structureless areas: brown (19%); White scales: in skin
                                                                                                                furrows (13%); Structureless areas: focal (11%); White scales: diffuse (9%); Lines: brown (9%); White scales: patchy (7%);
                                                                                                                Structureless areas: diffuse (7%); Perifollicular white color (4%); White scales: perifollicular (2%)
                                                          Pityrosporum folliculitis     2          60 (60)      Common findings: Follicular papules/pustules (100%); Vessels: dotted, linear with branches, linear curved (67%);
                                                                                                                Hypopigmentation of hair shaft (63%); Diffuse white scales (58%); Coiled to looped hairs (57%)
                                                                                                                Less common findings: Perifollicular white scales (18%)
                                                          Rhinofacial                   1           1 (1)       Common findings: Focal yellow/orange structureless areas (100%); Dotted and linear vessels (100%); White structureless areas
                                                          entomophthoromycosis                                  (100%); Scales (100%); Yellow dots (100%)
                                                                                                                Less common findings: -
                                                          Sporotrichosis                2           5 (5)       Common findings: Yellow-orange structureless areas (80%); Linear vessels (60%)
                                                                                                                Less common findings: Yellow structureless areas (20%); Linear vessels with branches
                                                                                                                (20%); White structureless areas (focal) (20%); Peripheral-radiating white lines (20%); Follicular plugs (20%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
                                                                                                                                                                                                                                   Table1 continues
                                                                                                   Total Number
                                                                                                    of Instances
                                                                                                     (Instances
                                                                                          Total         With
                                                                                         Number     Dermoscopy
                                                                                           of        Prevalence
                                                                Dermatoses               Studies        Data)                                               Dermoscopic Findings* (Total Prevalence)**
                                                          Tinea corporis                   2          43 (43)      Common findings: White scales (100%)
                                                                                                                   Less common findings: Scaly broken hairs (37%); White scales: peripheral (jagged outer free edge) (23%); Structureless areas:
                                                                                                                   brown (21%) focal (14%)/diffuse (7%); Brown dots (14%); Brown scales: peripheral (12%); Broken hairs (9%); White scales:
                                                                                                                   jagged mixed free edge (7%); Vessels: dotted (5%); White scales: perifollicular (5%); Yellow scales/crusts: peripheral (5%);
                                                                                                                   Structureless areas: focal white (2%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
                                                          Tinea incognito                  3          53 (53)      Common findings:
                                                                                                                   Less common findings: Morse code vellus hairs (34%); Follicular pustules (26%); Peripheral white scales (26%); Micropustules
                                                                                                                   at the borders (22%); Linear, linear curved, dotted vessels (20%); Purple areas (18%); Perifollicular scales (2%); Black dots
                                                                                                                   (2%); Dystrophic broken hairs (2%); Dotted vessels (2%)
                                                          Tinea manuum/pedis               2          11 (11)      Common findings: White scales (91%)
                                                                                                                   Less common findings: White scales in the skin furrows (9%); Dotted vessels in the skin furrows (9%)
                                                          White piedra                     1           1 (1)       Common findings: Creamy yellow nodules distributed along the hair at irregular interval (100%)
                                                                                                                   Less common findings: -

                                                          Parasitoses/bites and stings

                                                          Bed bug bites                    1           1 (1)       Common findings: Purple dot (100%)
                                                                                                                   Less common findings: -
                                                          Cydnidae pigmentation            4           4 (4)       Common findings: Brown lines (50%)
                                                                                                                   Less common findings: Brown dots/globules (25%); Brown dots (25%); Brown dots/lines (25%); Brown structureless area
                                                                                                                   (diffuse) (25%); Perifollicular pigmentation (25%)
                                                          Cutaneous larva migrans          1           1 (1)       Common findings: Well-defined, segmented yellow-white linear structure (100%); Brown dots with peripheral white scales
                                                                                                                   (100%)
                                                                                                                   Less common findings: -
                                                          Cutaneous leishmaniasis          3          17 (17)      Common findings: Follicular plugs (71%); White lines (65%); Ulceration (53%)                                       Table1 continues
                                                                                                                   Less common findings: Vessels: dotted (35%), linear (35%); Structureless areas: focal orange (35%); Structureless areas: white
                                                                                                                   (24%); Vessels: linear with branches (18%); Peripheral-radiating white lines (12%); Vessels (12%): linear, linear-curved




7
8
                                                                         Table 1. Total Number of Studies, Instances and of Standardized Dermoscopic Findings of Infectious Dermatoses in Skin of Color.



                                                                                                      Total Number
                                                                                                       of Instances
                                                                                                        (Instances
                                                                                           Total           With
                                                                                          Number       Dermoscopy
                                                                                            of          Prevalence
                                                                  Dermatoses              Studies          Data)                                                       Dermoscopic Findings* (Total Prevalence)**
                                                           Gamasidosis                        1             1 (1)        Common findings: Mite red to black in color engorged with blood (100%)
                                                                                                                         Less common findings: -
                                                           Pediculosis
                                                             Pediculosis capitis              1             1 (1)        Common findings: Empty nits (grey, translucent, ovoid eggs with flattened free ends) attached to the hair shaft (100%)
                                                                                                                         Less common findings: -

                                                             Pediculosis pubis                3             3 (3)        Common findings: Nits containing unhatched nymphs, translucent empty cases (33%); Active lice (33%); Nits attached to
                                                                                                                         eyelashes (33%); Crab-shaped pubic lice with thick claws grasping hair shaft (33%)
                                                                                                                         Less common findings: -
                                                           Post-kala azar                     3             3 (2)        Common findings: Follicular plugs (50%); Yellow structureless areas (50%)
                                                           leishmaniasis                                                 Less common findings: -
                                                           Tick bite                          1             1 (1)        Common findings: Tick with four pairs of limbs (100%)
                                                                                                                         Less common findings: -
                                                           Tungiasis                          1             1 (1)        Common findings: Central brown ring, central pore, and faint pigmented peripheral ring (100%); Peripheral white structureless
                                                                                                                         area (100%)
                                                                                                                         Less common findings: -
                                                           Wound myiasis                      1             1 (1)        Common findings: Larvae, caudal larval end with two oval openings, incomplete peritreme and prominent slits (100%)
                                                                                                                         Less common findings: -
                                                          *Dermoscopic findings for which a standardized terminology was available; the se are divided into common (prevalence ≥ 50%) and less common ( prevalence < 50 %)

                                                          **Total prevalence is calculated only considering studies for which prevalence data of dermoscopic findings was available




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
Figure 2. Examples of dermoscopic clues of bacterial diseases in dark-skinned patients: White structureless areas and reduction of eccrine
gland openings in borderline tuberculoid leprosy (Courtesy of Matilde Krisha Montenegro, MD and Katherine Joy Sayo, MD – Manila,
Philippines) (A); Yellow structureless areas along with white structureless areas, faint peripheral linear vessels with branches (arrow), and re-
duction of skin appendages (hairs/eccrine glands openings) in borderline lepromatous leprosy (B); Loss of pigment network along with white
areas and reduction of eccrine glands openings and hair follicles in lepromatous leprosy (C); Reduction of skin appendages, erythema, white
scales and follicular plugs in Type-1 lepromatous reaction (D); Homogenous white-pink area and brown-gray dots in Type-2 lepromatous
reaction (Courtesy of Matilde Krisha Montenegro, MD and Katherine Joy Sayo, MD – Manila, Philippines) (E); Elongated linear vessels with
branches and multiple white structureless areas in histoid leprosy (F).




Figure 3. Examples of dermoscopic clues of bacterial diseases in dark-skinned patients: Ill-defined white structureless area and reduction of
skin appendages in hypopigmented leprosy (A); Follicular plugs with perifollicular white color in lichen scrofulosorum (B); Orange-yellow
and bright white globules/structureless areas along with diffuse white scaling in lupus vulgaris (C); Peripheral white collarette scaling in
palmar secondary syphilis (D); Yellow concretions around the hair shafts in trichomycosis axillaris (E); Multiple white globules (papillae)
centered by dotted vessels in tuberculosis verrucosa cutis (F).




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S                                                                                        9
Figure 4. Examples of dermoscopic clues of viral diseases in dark-skinned patients: Multiple yellow-white globules and peripheral linear
vessels with branches in molluscum contagiosum (A); Central pore surrounded by white globules/dots along with peripheral dotted vessels in
molluscum contagiosum (B); Brown dots and dotted vessels over a white background in a plane wart (C); Brown structureless area (diffuse)
and few dotted vessels in plane warts (D); Interruption of skin markings, dotted vessels and diffuse brown pigmentation in a common wart
(E); Multiple grey papillae in a genital wart (F).




leprosy, in which an accentuation of pigment network sec-              structures (structureless or linear areas), yellowish-brown
ondary to basal layer pigmentation was described [10,12].              to pink structureless areas, peripheral hyperpigmentation,
Finally, Mohta et al found relative sparing of vellus hair in          scaling, follicular plugs and vessels (linear with branches
tuberculoid pole, whereas focal areas of hyperpigmentation             or ­linear-curved) [10,12,18-20]. Finally, regarding hypopig-
with loss of pigment network were seen in borderline lepro-            mented forms of leprosy, Errichetti et al reported that reduc-
matous cases [12].                                                     tion of skin appendages was a clue to differentiate them from
     Moving    to    lepromatous     reactions,    four    studies     other hypopigmented dermatoses in a case-control study [9].
(case-series/reports) exist for both type-1 reaction (T1R)
[10,12,13,16] and type-2 reaction (T2R) [10,12,13,17].                 Lichen Scrofulosorum
The most common dermoscopic features of T1R were di-                   Dermoscopy of lichen scrofulosorum has been investigated
lated vessels (mainly linear with branches), white scales,             in two reports and described findings included monomor-
follicular plugs, and white/yellow-orange structureless areas          phic, grouped, brown follicular plugs along with pale halos
[10,13,16], while T2R has been described to show mainly                as well as a peripheral white scales, marginal hyperpigmen-
hyperpigmentation (shape/color not specified) and dilated              tation, and dilated vessels [21,22].
linear vessels with branches [10,12,13,17]. Recently, homog-
enous white-pink structureless area with irregular border              Lupus Vulgaris
having a crumpled fabric appearance with peripheral brown-             Data about dermoscopy of lupus vulgaris (LV) comes from a
gray dots/globules was noted in an instance of bullous T2R             case-control analysis by Errichetti et al involving 12 patients
[17]. Notably, dermoscopic findings characteristic of under-           [9] and a case-series on 19 instances by Ankad et al [23].
lying leprosy subtype have also been described in reactional           ­Yellow-orange structureless areas (mainly focal), linear vessels
states [10,12,13,16,17].                                               (mainly with an unspecific distribution), white scales, and fo-
     Considering histoid leprosy, five studies have been re-           cal bright white (fibrotic) structureless areas were the most fre-
ported (case-series/reports), with white/white-yellow and              quent findings. Of note, Errichetti et al found that the presence
yellowish orange structureless areas being the main dermo-             of focal bright white areas was typical of LV when compared
scopic features. Additional findings included shiny white              with other granulomatous diseases, including sarcoidosis.




10                                                                              Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
Figure 5. Examples of dermoscopic clues of fungal diseases in dark-skinned patients: White and yellow scaling/crusting, dotted vessels and
purple (hemorrhagic) dots/globules along with yellow structureless areas and brown dots (better visible in the inset) in chromoblastomycosis
(A); White scales, yellow and white structureless areas, and black grains (dots) (arrow) in mycetoma (B); Perifollicular white color along
with white scales in the skin furrows in hypopigmented pityriasis versicolor (C); Folliculocentric pale papule in Pityrosporum folliculitis (D);
Focal orange and white structureless areas and white scales in rhinofacial entomophthoromycosis (E); Follicular plugs and unfocused linear
vessels over an orange-erythematous background in sporotrichosis (adapted from Dermoscopy in General Dermatology for Skin of Color,
Errichetti E, Lallas A, eds. CRC Press 2021) (F); White peripheral collarette scaling with a jagged mixed (outer and inner) free edge in tinea
corporis (G); Follicular pustules, perifollicular scaling/crusting and dystrophic broken hairs in tinea incognito (H); White scales in the skin
furrows in tinea manuum (I).




Syphilis                                                                  yellow-orange globules and structureless areas, papillated
A single report on dermoscopy of syphilis is available for skin           surface, dirty white thick scales, and irregularly dilated ves-
of color [24]. The authors evaluated an instance of second-               sels being observed [26].
ary syphilis and found ill-defined, brown structureless area
                                                                          Viral Infections
fading towards the periphery along with white scaling in the
                                                                          Molluscum Contagiosum
skin furrows in body lesions, while an orange structureless
area and white scaling were reported in palmar lesions [24].              Four studies are available when it comes dermoscopy of mol-
                                                                          luscum contagiosum (one case-control study, one case series
Trichobacteriosis Axillaris                                               and two single reports) [9,27-29]. Most data comes from the
A single dermoscopic description of trichobacteriosis axil-               case-control study by Errichetti et al involving 10 instances
laris does exist, with detection of golden yellow concretions             that showed white globules to be the main feature [9], in
encasing multiple hair shafts along their length [25].                    line with other reports [27,28]. Additional findings included
                                                                          peripheral dotted or linear vessels with branches [9,27,28].
Tuberculosis Verrucosa Cutis                                              Of note, white globules with visible vessels running across
Only a single report describing dermoscopy of tubercu-                    the surface were also reported by Daruwalla et al, who per-
losis verrucosa cutis is available in the literature, with                formed extraction dermoscopy in 20 patients [29].



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S                                                                                     11
Figure 6. Examples of dermoscopic clues of skin bites/stings and parasitoses in dark-skinned patients: purple dots and crusting in bedbug
bites (A); Brown structureless areas and lines (in the skin furrows) in cydnidae pigmentation (B); Well-defined, segmented brown/white linear
structures in cutaneous larva migrans (C); Multiple follicular plugs in cutaneous leishmaniasis (D); Empty nits (translucent elongated struc-
tures with flat ending) and head lice in pediculosis capitis (E); Crab-shaped pubic lice with thick claws grasping hair shaft in pediculosis pubis
(F); Central crusting with peripheral brown structureless area surrounded by a white halo in tick bite (G); Central pore with a faint pigmented
peripheral ring and peripheral white structureless area containing blue globules in tungiasis (Courtesy of Elizabeth Leocadia Fernandes, MD
– Mogi das Cruzes, Brazil) (H); Myasis larva (I).




Warts                                                                      Fungal Infections
Six studies (one case-control study, four case-series and                  Chromomycosis
one single report) assessed dermoscopic patterns of warts                  Dermoscopy of chromomycosis has been described in four
(including common, palmoplantar, plane and genital sub-                    single reports, with brown/black dots and yellow-orange
types) [9,30-34]. In detail, the main findings of common                   structureless areas, and white scales/crusts being constantly
warts included brown dots, dotted vessels and black dots/                  reported [35-38]. Additionally, white reticular lines [35-38]
globules (thrombosed vessels) over a white background. Pal-                and polymorphic vessels [36,38] were also observed in half
moplantar warts showed a similar pattern, though they were                 of published instances.
also commonly reported to display papillary projections, in-
terruption of skin markings, and perivascular white halos                  Mycetoma
besides the aforementioned findings. With regard to plane                  Three single reports describing dermoscopic pattern of
warts, brown background was a constantly reported feature,                 mycetoma are available in the literature [39-41]. The most
while dotted vessels were described in a minority of cases.                typical feature reported was the presence of white-yellow/
Finally, dotted vessels were the most commonly described                   yellow globules/structureless areas and grains (globules cor-
findings in genital warts, followed by linear vessels and blu-             responding to microbial masses), whose color varied based
ish background.                                                            on the subtype (red/white in actinomycetoma and black in
                                                                           eumycetoma) [39-41].



12                                                                                  Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S
Pityriasis Versicolor                                             the case-series by Bhat et al on ten instances that found white
Pityriasis versicolor (PV) is the most studied fungal derma-      scales along creases to be a constant clue [51], in line with
tosis from a dermoscopic point of view, with a case-control       another single report [52].
study, two case-series and two case-report for a total of 184        Moving to TC, in their case-series involving 30 patients,
patients [9,42-45]. The main finding of both hypo- and            Bhat et al found white scales (not specified arrangement) to
­hyper-pigmented variants was the presence of white scales        be the most frequent finding (all cases), followed by scaly
in the skin furrows (over a dull diffuse white or brown back-     broken hair (half of the cases) [51]. Whereas, in a case-­control
ground, respectively); notably, such a pattern of scaling was     study by Errichetti et al including 13 instances, peripheral
reported to be specific of PV when compared to other pig-         white scales showing a jagged outer free edge turned out to
mentary disorders in the study by Errichetti et al [9]. Sim-      be specific for TC when compared to other papulosquamous
ilarly, although less frequent, the detection of perifollicular   dermatoses [9]. Additionally, although less frequent, also pe-
white scaling was found to be peculiar of PV over the other       ripheral yellow and brown scales were peculiar of TC.
analyzed conditions. Further characteristic findings described       With regard to tinea incognito, in the first report on a
by Kaur et al included the so-called “contrast halo sign” (ring   single instance, Sonthalia et al reported follicular findings
of alternate pigmentation surrounding the primary lesion)         to be the main clues, including perifollicular scales, black
and folliculocentricity [43]. The latter feature (reported as     dots, and hair-shaft changes (i.e., broken/bent deformable
perifollicular white halo) was found to be specific in the com-   hairs, “morse code” hairs, and transparent hairs) [53]. These
parative analysis by Errichetti et al in achromic PV [9].         dermoscopic features were subsequently validated by two
                                                                  case-series on a total of 52 patients [51,54].
Pityrosporum Folliculitis
                                                                  White Piedra
Two case-series involving a total of 60 cases have analyzed
                                                                  Dermoscopy of white piedra has been investigated in a single
dermoscopy of pityrosporum (Malassezia) folliculitis (PF),
                                                                  report, that showed creamy yellow nodules distributed along
with folliculocentricity and perilesional erythema reported
                                                                  the hair at irregular intervals [55], differently from tricho-
to be constant findings [46-47]. Additional common (>75%
                                                                  bacteriosis axillaris that tends to feature yellow concretions
of the analyzed instances) findings included (dotted, linear or
                                                                  along the entire length of the hair shaft [55].
linear-curved) in and around lesions and diffuse/peripheral
white scales [46,47].
                                                                  Skin Parasitoses and Insect Bites/Stings
Rhinofacial Entomophthoramycosis                                  Bed Bug Bites
A single dermoscopic report on rhinofacial entomophthora-         A single report describing dermoscopy of bed bug bites has
mycosis does exist, with focal yellow-orange structureless        been retrieved, with evidence of a central hemorrhagic punc-
areas and dotted/linear vessels being reported as the main        tum surrounded by erythema [56]. The authors also performed
features [48]. Additional findings included white structure-      ex vivo dermoscopic examination showing multiple bed bugs
less areas, scaling, and follicular plugs [48].                   and their empty eggs (appearing white and translucent) [56].

Sporotrichosis                                                    Cydnidae Pigmentation
Dermoscopy of sporotrichosis has mainly been described            Four single reports described dermoscopic features of cyd-
in a case-series on four patients (including cutaneous and        nidae pigmentation [57-60].The main feature consisted of
lymphocutaneous subtypes) by Vinay et al, that reported           brown dots/globules and/or lines [57,59,60]. Additionally,
yellow-orange areas and hemorrhagic crusting as constant          Jindal et al observed the presence of orange-brown structure-
findings [49]. Of note, the presence of yellow areas was also     less areas with ridge enhancement over the sole, thereby sug-
described in another single case of disseminated cutaneous        gesting that the pigment released by the bug seeps through
sporotrichosis [50]. Vinay et al also found dermoscopic vari-     the skin dermatoglyphics [58].
ability based on lesions localization and duration, with fa-
cial involvement also featuring follicular plugs and early and    Cutaneous Larva Migrans
healing lesions respectively showing yellow-orange struc-         Only a single report describing dermoscopic pattern of cu-
tureless areas along with variable dilated vessels and white      taneous larva migrans is available in the literature [61]. The
(fibrotic) structureless areas with linear vessels [50].          authors observed well-defined segmented yellowish-white
                                                                  lines (corresponding to larval body), along with brown dots
Tinea Infections                                                  and peripheral white scales (representing empty larval tract)
Information on dermoscopic patterns of tinea manuum/pe-           in the central part and multiple yellowish lines (reflecting
dis, tinea corporis (TC) and tinea incognito is available. Re-    pustules over the larval tract secondary to inflammation) in
garding tinea manuum/pedis, most knowledge comes from             the distal half of the lesion [61].

Review | Dermatol Pract Concept. 2023;13(4)S1:e2023309S                                                                        13
Cutaneous Leishmaniasis                                             Conclusions
Most evidence on dermoscopy of cutaneous leishmaniasis
(CL) comes from the case-control study by Errichetti et al          The present review analysis underlines that dermoscopic
including 14 instances that found follicular plugs, white lines     knowledge on infectious dermatoses mainly comes from sin-
(mainly peripheral-radiating), and ulceration (especially cen-      gle reports, with a limited number of larger studies showing
tral) to be specific clues over other granulomatous derma-          a high level of evidence. Moreover, the reproducibility of re-
toses [9]. Such findings were also observed in two reports          ported findings may also be limited by the highly variable
involving a total of 3 cases [62,63].                               terminology used in the retrieved studies. Hence, even though
                                                                    infectiouscopy is a promising aid for dermatologist, as it may
Gamasidosis                                                         facilitate the detection of subclinical findings strictly related
In a single report on gamasidosis (avian mite dermatitis),          to specific histological and/or microbiological features, fur-
Toukabri et al utilized dermoscopy to identify the mite, which      ther studies designed according to a systematic and stan-
appeared red to black colored and replete with blood [64].          dardized approach are needed for better characterization.

Pediculosis
Only four single reports have been retrieved (one each for pe-      References
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