10.5826/dpc.1303a174
Introduction: Dermatoscopy is gaining appreciation in assisting the diagnosis of inflammatory dermatoses (inflammoscopy). Lichen planus (LP) is a common inflammatory skin disease with characteristic dermatoscopic features.
Objectives: The objective of this study was to review the literature on the dermatoscopy of lichen planus and to re-evaluate the published descriptions in the light of the 2019 expert consensus on the terminology of dermatoscopy for non-neoplastic skin diseases.
Methods: We searched the PubMed database using the keywords ‘lichen planus and dermatoscopy’, ‘lichen planus and dermoscopy’, ‘lichen planus and epiluminescence microscopy’, and ‘lichen planus and inflammoscopy’.
Results: Of 413 articles retrieved, we selected 67 articles for full-text review, and finally included 63 articles, mostly case reports or small case series, comprising 572 patients with lichen planus. We identified 113 different terms or short descriptions that were used to characterize the dermatoscopy of lichen planus. Frequently, authors applied various terms to variants of the same feature. Although reported under different designations, Wickham striae were the most consistent dermatoscopic feature of lichen planus. Other characteristics of lichen planus, such as vascular patterns, pigmented structures, and follicular findings were less consistent or depended on skin type, anatomic site, disease stage, and applied treatment.
Conclusions: While Wickham striae are the single most important clue for diagnosis, other dermatoscopic characteristics of lichen planus are less consistent. Based on descriptions published in the literature we established a dictionary of useful terms for the description of lichen planus that is consistent with the terminology suggested by the recent consensus conference.
text/xml
2160-9381
2798
en
Harald Kittler
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
lichen planus
Dermatoscopy of Cutaneous Lichen Planus – Attempt to Translate Metaphoric Terminology Into Descriptive Terminology
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-08-31
2023-07-31
2023-10-05
e2023174
Dermatol Pract Concept
Introduction: Dermatoscopy is gaining appreciation in assisting the diagnosis of inflammatory dermatoses (inflammoscopy). Lichen planus (LP) is a common inflammatory skin disease with characteristic dermatoscopic features.
Objectives: The objective of this study was to review the literature on the dermatoscopy of lichen planus and to re-evaluate the published descriptions in the light of the 2019 expert consensus on the terminology of dermatoscopy for non-neoplastic skin diseases.
Methods: We searched the PubMed database using the keywords ‘lichen planus and dermatoscopy’, ‘lichen planus and dermoscopy’, ‘lichen planus and epiluminescence microscopy’, and ‘lichen planus and inflammoscopy’.
Results: Of 413 articles retrieved, we selected 67 articles for full-text review, and finally included 63 articles, mostly case reports or small case series, comprising 572 patients with lichen planus. We identified 113 different terms or short descriptions that were used to characterize the dermatoscopy of lichen planus. Frequently, authors applied various terms to variants of the same feature. Although reported under different designations, Wickham striae were the most consistent dermatoscopic feature of lichen planus. Other characteristics of lichen planus, such as vascular patterns, pigmented structures, and follicular findings were less consistent or depended on skin type, anatomic site, disease stage, and applied treatment.
Conclusions: While Wickham striae are the single most important clue for diagnosis, other dermatoscopic characteristics of lichen planus are less consistent. Based on descriptions published in the literature we established a dictionary of useful terms for the description of lichen planus that is consistent with the terminology suggested by the recent consensus conference.
Harald Kittler
2023/07/31
10.5826/dpc.1303a174
e2023174
Department of Dermatology, Medical University of Vienna, Vienna, Austria
2160-9381
lichen planus
en
e2023174
Eirís N, Vázquez-López F, Palacios-García L, González-Lara L, González-Fernández D, Argenziano G. Value of dermoscopy for the differential diagnosis of Wolf's post herpetic isotopic response. Australas J Dermatol. 2015;56(1):29-31. DOI: 10.1111/ajd.12138. PMID: 24428406.
Dermatoscopy of Cutaneous Lichen Planus – Attempt to Translate Metaphoric Terminology Into Descriptive Terminology
https://dpcj.org/index.php/dpc/article/download/2798/2240
                Dermatoscopy of Cutaneous Lichen
             Planus – Attempt to Translate Metaphoric
             Terminology Into Descriptive Terminology
          Agata Szykut-Badaczewska1, Mariusz Sikora2, Lidia Rudnicka3, Harald Kittler4


1 Department of Dermatology and Venereology, State Hospital Klagenfurt, Klagenfurt am Wörthersee, Austria
2 National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
3 Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
4 Department of Dermatology, Medical University of Vienna, Vienna, Austria



Key words: dermatoscopy, dermoscopy, descriptive terminology, inflammoscopy, lichen planus
Citation: Szykut-Badaczewska A, Sikora M, Rudnicka L, Kittler H. Dermatoscopy of Cutaneous Lichen Planus – Attempt to Translate
Metaphoric Terminology into Descriptive Terminology. Dermatol Pract Concept. 2023;13(3):e2023174.
DOI: https://doi.org/10.5826/dpc.1303a174
Accepted: February 26, 2022; Published: July 2023
Copyright: ©2023 Szykut-Badaczewska 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: HK reports royalties or licenses from Casio, Barco and MetaOptima, speaker honoraria from FotoFinder, and receipt
of equipment for testing from FotoFinder, 3Gen, DermaMedicalSystems, Heine and Casio; all outside the submitted work. The other
authors have no conflicts of interest to disclose.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Agata Szykut-Badaczewska, Department of Dermatology and Venereology, State Hospital Klagenfurt, Klagenfurt
am Wörthersee , Austria, Tel. +43 463 538-32603, E-mail: agata.szykut-badaczewska@kabeg.at




  ABSTRACT             Introduction: Dermatoscopy is gaining appreciation in assisting the diagnosis of inflammatory
                       ­dermatoses (inflammoscopy). Lichen planus (LP) is a common inflammatory skin disease with charac-
                        teristic dermatoscopic features. Over the last few years, numerous articles were published on the der-
                        matoscopy of LP and a high number of terms have been used to describe the dermatoscopic features
                        of this disease.
                       Objectives: The objective of this study was to review the literature on the dermatoscopy of LP and to
                       re-evaluate the published descriptions in the light of the 2019 expert consensus on the terminology of
                       dermatoscopy for non-neoplastic skin diseases.
                       Methods: We searched the PubMed database using the keywords ‘lichen planus and dermatoscopy’,
                       ‘lichen planus and dermoscopy’, ‘lichen planus and epiluminescence microscopy’, and ‘lichen planus
                       and inflammoscopy’.




Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                       1
                      Results: Of 408 articles retrieved, we selected 67 articles for full-text review and finally included
                      58 articles, mostly case reports or small case series, comprising 572 patients with LP. We identified
                      118 different terms or short descriptions that were used to characterize the dermatoscopy of LP and
                      redescribed them according to International Dermoscopy Society consensus paper. Frequently, au-
                      thors applied various terms or descriptions to variants of the same feature. Although reported under
                      different designations, Wickham striae were the most consistent dermatoscopic feature of LP. Other
                      characteristics of LP, such as vascular patterns, pigmented structures and follicular findings were less
                      consistent or depended on skin type, anatomic site, disease stage and applied treatment.
                      Conclusions: While Wickham striae are the single most important clue for the diagnosis, other derma-
                      toscopic characteristics of LP are less consistent. Based on the descriptions published in the literature
                      we established a dictionary of useful terms for the description of LP that is consistent with the termi-
                      nology suggested by the recent consensus conference.




Introduction                                                       including the genitalia (penile or vulvar LP), esophagus,
                                                                   conjunctiva, and skin appendages may also be affected [6,8-
Dermatoscopy is a non-invasive diagnostic technique that           9]. The typical primary lesion of cutaneous LP is a papular
is widely used for in vivo examinations of skin lesions.           eruption characterized by the development of flat-topped,
It improves the diagnostic accuracy for pigmented and              violaceous papules on the skin [6,8]. In 1895, Wickham
non-pigmented cutaneous proliferations and enables users           noted the characteristic reticulate white lines on the surface
to detect criteria that are invisible with the unaided eye.        of LP papules now recognized as Wickham striae [10]. Often,
­Application of dermatoscopy is straightforward and fast and       a mnemonic (‘4 P’s’ or ‘5 P’s’) is used to describe the skin
can be easily incorporated into clinical routine [1-3]. An in-     lesions associated with LP, which includes planar, polygonal,
creasing number of publications on alternative applications        pruritic, purple papules or plaques [8,10]. Approximately
of dermatoscopy suggests that dermatoscopy is gaining ap-          50% of patients with active LP may show an isomorphic re-
preciation for the diagnosis of non-neoplastic skin diseases,      sponse (the development of lesions of LP in sites of trauma,
such as inflammatory skin diseases and skin infections and         commonly as a result of scratching) [6,8]. The predilection
­infestations [2-4]. Due to its broader scope, the vocabulary      sites of LP include the extensor surfaces of the lower legs and
of dermatoscopy expanded significantly over the last few           the volar aspect of the wrists and forearms, trunk and the
years [2]. Dermatoscopic terms used in the literature are nu-      lumbar region [6]. LP is mainly a self-limited dermatosis. The
merous and often incomprehensible, which prevents a sys-           mean duration of the disease is estimated at about 1–2 years
tematic analytic approach [2-3,5].                                 but longer and chronically recurrent courses are possible [6].
    In 2019, the International Dermoscopy Society (IDS)            Lesions tend to heal with significant post-inflammatory hy-
published a consensus paper on standardization of dermo-           perpigmentation especially in individuals with dark skin
scopic terminology in non-neoplastic dermatoses [5]. A set         tone [8]. In addition to the classic variant of cutaneous LP,
of the following 5 dermoscopic parameters was proposed as          other multiple clinical presentations of the disease have been
a basic guide to use in general dermatology: (I) vessels (in-      described. Combinations of morphological variants are pos-
cluding morphology and distribution); (II) scales (including       sible in the individual case [6,8]. Examples of variants of LP
colour and distribution); (III) follicular findings; (IV) ‘other   are given in Table 1 [6,8,11]. In many cases, the diagnosis of
structures’ (structures other than vessels/scales; including co-   cutaneous LP can be made clinically. In doubtful cases a skin
lour and morphology); and (V) ‘specific clues’ (features that,     biopsy is useful to confirm the diagnosis [8]. Occasionally,
when present, are strongly suggestive of only 1 diagnosis due      direct and indirect methods for immunofluorescence may be
to a strict dermoscopic-pathological correlation) [3].             helpful in the diagnostic process of LP [6,12].
    Lichen planus (LP) is an inflammatory skin disorder, often
with a chronic course [6]. The term LP was coined by Eras-
                                                                   Objectives
mus Wilson in 1869 [7]. Data on the epidemiology of LP are
scarce but it is believed to be common [8]. The disease com-       The main aims of this study were (1) to retrieve and analyse
monly affects middle-aged adults, between 30 and 60 years of       the dermatoscopy terminology of cutaneous LP and (2) to
age. The skin (cutaneous LP) and oral cavity (oral LP) are the     revaluate the published descriptions in the light of the IDS
most frequently involved areas. Other mucous membranes,            consensus 2019.




2                                                                      Original article | Dermatol Pract Concept. 2023;13(3):e2023174
       Table 1. Clinical variants of cutaneous                    Results
                   lichen planus.
                                                                  Wickham striae (WS) are the dermatoscopic hallmark of LP.
                       Clinical variants
                                                                  WS most often appear as white lines but occasionally may be
     Classic LP
                                                                  yellow or, rarely, even blue, for example in palmo-plantar le-
     Hypertrophic LP
                                                                  sions of patients with darker skin tone [3,14]. The most com-
     Annular LP
                                                                  mon arrangement of WS is the reticular pattern [14] (Figure
     Bullous LP
                                                                  2). Less commonly, WS may not be arranged in a reticular
     Erythrodermic LP                                             fashion. These variations in the arrangement of WS have
     LP pemphigoides                                              been described in the literature as annular, circular, round,
     Lichen planus-lupus erythematosus overlap syndrome           arboriform, perpendicular, veil-like, ‘leaf venation’, ‘starry
     LP actinicus                                                 sky’ or structureless, polymorphic and combined [11,14-25].
     LP pigmentosus                                                  In scarring or resolving lesions of dermatoses other than
     LP pigmentosus-inversus                                      LP (e.g. discoid lupus erythematosus, prurigo nodularis), a
     Atrophic LP                                                  network-like white structure similar to Wickham striae may
     Follicular LP (Lichen planopilaris)                          be seen. These structures, which result from dermal fibro-
     LP follicularis decalvans                                    sis, are defined as pseudo-Wickham striae [3,11]. Additional
     Regressive lichen planus                                     features of active LP frequently reported in the literature are
                                                                  peripheral dotted or linear vessels; structureless backgrounds
     Acute generalized lichen planus
                                                                  of various colours including violet, reddish, pink, brown or
     Ulcerative LP
                                                                  yellow; white or yellow dots, and pigmented structures (dots,
     Linear LP
                                                                  globules and/or reticular or cloud-like areas) [14].
     Nail LP
                                                                     Palmar LP is characterized by roundish yellowish areas
     Oral LP
                                                                  with peripheral projections that may create a star-like ap-
     Genital LP
                                                                  pearance [14], which may correspond to the specific man-
     Esophageal LP                                                ifestation of Wickham striae in palmar skin. Madke et al
     Otic LP                                                      described black colored patches on the palms for which the
LP = lichen planus.                                               term ‘hem-like pattern’ was coined. It corresponds to pig-
                                                                  ment distribution along the ridges [26]. Dermatoscopy of a

Methods                                                           plantar lichen planus, presented in another article published
                                                                  by Madke et al, showed scaling and a reticular pattern [7]
We conducted a systematic literature review searching the         (Figure 3).
PubMed database according the Preferred Reporting Items              Dermatoscopy of hypertrophic LP lesions is typified by
for Systematic Reviews and Meta-Analyses (PRISMA) guide-          a rippled surface, comedo-like structures filled with yel-
lines [13]. We searched for relevant articles in English using    low keratinous plugs, round structures (‘corn pearls’) and
the keywords ‘lichen planus dermatoscopy’, ‘lichen planus         blue-gray globules (Figure 4). Less common features include
dermoscopy’, ‘lichen planus epiluminescence microscopy’           non-specific vascular findings (red globules, linear and dot-
and ‘lichen planus inflammoscopy’ and identified 401 publi-       ted vessels), white structureless areas, scaling and central
cations. The titles and abstracts were screened and 51 articles   hyperpigmentation [14]. WS are often invisible in hypertro-
were selected for full-text review. Publications on hair, nail    phic LP, as they are covered by the overlying hyperkeratosis
and mucous membrane involvement were excluded. A man-             [3,22,27].
ual search was also carried out by analysing the reference           The main dermatoscopic patterns of LP pigmentosus in-
sections of all relevant articles about dermatoscopy of cuta-     clude a diffuse, structureless, brownish pigmentation, gray,
neous LP. In total, 58 articles were selected for full-text-re-   blue or brown dots (‘peppering’) or globules (clods). Other
view, including 34 case reports and case series, 9 reviews and    findings such as perifollicular pigmentation and white dots
overviews, 3 retrospective studies and 12 prospective stud-       are less common [14,28-29]. In LP pigmentosus WS are typ-
ies (Figure 1). One of the authors made a list of terms and       ically absent [30]. It is worth mentioning that a special form
phrases that were used to describe the dermatoscopy of LP.        of lichen planopilaris - frontal fibrosing alopecia - may coex-
We excluded phrases and terms that could be understood            ist with lichen planus pigmentosus. It was firstly reported by
outside the context of dermatoscopy (e.g. crusting, erosions).    Dlova in 2013 [31-32].
The final list consists of 118 terms and phrases (Table 2).          Lichen planus pigmentosus-inversus (LPPI), a rare
                                                                  ­subvariant of lichen planus pigmentosus, first described by



Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                 3
    Figure 1. PRISMA flow diagram of study selection for inclusion in the systematic review.




     Figure 2. Lichen planus. (A) Clinical image. (B) Dermatoscopy shows classic Wickham striae (white lines in reticular arrangement),
     keratin plugs that appear as yellow clods and vessels as dots. Scale is also present but this is not a typical feature of lichen planus.


Pock in 2001, is characterized by hyperpigmented macules or                but with time, they form reticular, linear, and cobblestone
plaques located in the intertriginous and flexural areas [8,33].           patterns. In some instances of LPPIs more than one pattern
The dermatoscopy in LPPI is typified by brown structureless                can be found dermatoscopically. The white dots described in
areas and gray dots and clods. Initially gray dots are grouped,            LPPI result from the lack of pigmentation of the follicular



4                                                                               Original article | Dermatol Pract Concept. 2023;13(3):e2023174
    Table 2. Lichen planus metaphoric presented in literature vs. suggested descriptive terminology.
                                                                                                               References
                                                                                                                # (where
            Suggested terminology                                Terms and phrases found in literature         described)
 Wickham striae (specific clue)
 White or gray peripheral parallel lines and          peripheral striations with pearly white areas                       27
 structureless in the centre                          (or milky-white structures at the centre and grayish
                                                      strands arranged peripherally)
 White circles and white branched or curved           annular and arboriform whitish line                                 37
 lines
 White reticular lines                                reticular pearly white areas                                        35
 Blue, gray reticular lines                           reticular pigmentation with blue-gray WS                            35
 Branched or curved lines                             WS: arboriform or arborizing                                        24
 Lines                                                WS: linear                                                          41
 Reticular lines                                      WS: reticular                                                       41
 Reticular lines                                      network of whitish striae                                           42
 Reticular lines                                      reticular streaks                                                   16
 Radial lines                                         white linear streaks arranged in a radial manner                    43
                                                      (starburst pattern)
 White reticular lines                                white crossing lines                                                36
 White reticular lines                                white crossing streaks                                              39
 Branched lines, connected to a common base           WS: leaf venation pattern (mimics snow crystal;                     21
 at one side, linked together on the other side       ‘fern leaf’ aspect)
 Perpendicular lines                                  WS: perpendicular                                                   11
 Reticular lines                                      WS: cross-linked                                                    16
 White radial lines                                   WS: white streaming lines                                           24
 Radial lines                                         WS: radial streaming                                                11
 Parallel lines                                       WS: projections, thin spikes (comb-like appearance)                 25
 Branched or curved thin or thick lines               WS: thin or broad arboriform projections,                           25
                                                      ramifications
 Yellow reticular or branched lines                   yellowish structures (in a lacy network), lacy network              37
                                                      pattern
 White straight lines                                 WS: longitudinal pearly-whitish lines                               23
 Reticular lines                                      lacy reticular striae                                                 7
 Parallel lines                                       WS ‘brush-like’                                                     47
 Clods globules                                       WS: globular                                                 16,20,37
 Circle                                               WS: round                                                    17,23,41
 Circle                                               WS: circular                                              17,20,24,37
 Circle                                               WS: annular                                                   1,15,37
 White circles                                        white streaks of annular pattern                                    24
 White circle between brown diffuse dots              invisible WS                                                        11
 White circles with white lines                       annular crystalline white striae                                    15
 White structureless zone                             PWS=pearly white structures                                         19
 Structureless zone                                   WS: structureless                                                16,43
 More than 1 type, undefined                          WS: combined morphology                                             11
 More than 1 type, undefined                          WS: polymorphic pearly whitish structure                            25
 Structureless zone                                   WS: veil-like                                                    16,20
 White structureless zone                             WS: homogeneous pearly-whitish configuration                        18
 White structureless zone                             WS: homogeneous crystalline white (striae)                          24


                                                                                                               Table2 continues



Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                  5
    Table 2. Lichen planus metaphoric presented in literature vs. suggested descriptive terminology.
                                                                                                                   References
                                                                                                                    # (where
            Suggested terminology                       Terms and phrases found in literature                      described)
Lines
Pigmented lines                                  linear pigment pattern                                                        11
Reticular lines                                  reticular pigment pattern                                                     11
Brown, blue, gray straight lines                 brownish to bluish-gray rods                                                  44
Angulated or polygonal lines                     rhomboidal structures                                                         45
Fragmented angulated lines                       broken lines, semi-arcuate structures (Chinese letters)                       46
Reticular lines                                  lacy reticular pattern                                                          7
Radial lines parallel to white lines             pigment streaming lines, pigmented lines streaming                            24
                                                 around a waned WS
Globules and dots
Follicular plugs                                 follicular plugging                                                           27
Blue, gray, brown, black globules                bluish-gray, brownish-black, brown globules                            27,44,45
Blue, gray globules arranged randomly,           blue-gray globules arranged in diffuse structureless                          37
around white structureless zones                 pattern interspersed in pearly white areas
Brown, yellow or orange (rarely black)           comedo-like openings, comedo-like structures                           22,48,49
globules or simply ‘keratin plugs’               (resembling oil drops)
White globules or dots                           milia-like cysts                                                           33,48
Pigmented globules                               pigmented globules, pigment globules                                       16,24
Pigmented polygonal globules                     cobblestone pigment pattern                                            11,12,16
Yellow polygonal globules                        roundish yellow areas often having peripheral                                 14
                                                 projections (star-like appearance)
Globules (rounded, corned structures)            round corneal structures                                                      14
                                                 ‘corn pearls’
White or black globules                          comedones                                                                     33
Gray, blue, brown globules and dots              fine/coarse, gray-blue/brown dots or globules                                 14
Brown clustered globules and dots                mottled pattern                                                               23
Globules and dots located centrally in the       ashy holes                                                                 23,50
lesion
Brown globules, dots                             brown punctate areas                                                          51
Four white dots, 4-dot globule                   rosettes                                                                      41
White clustered dots and gray dots               starry sky, starry sky pattern                                  14,16,17,21,24
White follicular clustered dots                  starry sky/white dots                                               14,16,21,24
Black dots                                       black pepper-like pattern                                                     12
Gray dots                                        peppered pigment, peppering pigment pattern                                16,24
Brown diffuse dots                               peppering, diffuse                                                            52
Gray dots and circles                            annular-granular pattern                                                      16
Globules and dots arranged in lines              hem-like pigment pattern, hem-like pattern                                    25
Gray, blue dots                                  gray, blue-gray granules                                                   19,53
Gray, brown dots                                 granular gray-brown dots                                                   50,54
Brown dots in the centre of hypopigmented        targetoid lesion, owl eye appearance                                          46
globules
Globules and dots arranged in lines that are     dots and globules in arcuate pattern                                          55
connected at an angle
Circles
Circle                                           pigmentation: follicular                                                      56
Gray, brown, blue circles, or dots arranged in   periappendageal, perifollicular, peri-eccrine gray to                         56
circles, or dots                                 brown/gray blue pigment deposition



6                                                                      Original article | Dermatol Pract Concept. 2023;13(3):e2023174
                                                                                                                      References
                                                                                                                       # (where
            Suggested terminology                                Terms and phrases found in literature                described)
 Concentric circles                                   hair follicles with central black dots (isobar sign)                        52
 Incomplete circles                                   areas with gray, blue-gray dots arranged in circles                         57
 White circles                                        ring-form whitish striae                                                 58,59
 Gray, brown, blue circles                            circular pigment pattern                                                    11
 Structureless
 Polychromatic structureless zone                     rainbow pattern                                                             41
 Brown structureless zone                             brown patches                                                            48,54
 Gray structureless zone                              gray patches                                                                48
 Gray and brown structureless zone                    mix of gray and brown                                                       48
 Brown or gray dots with brown structureless          mixed pigmented pattern                                                  21,60
 zones
 White and blue structureless zone                    blue-white veil                                                             24
 White and blue structureless zone                    homogeneous white-bluish pattern                                            33
 White and blue structureless zone                    blue and white curtain structure                                            61
 White or yellow structureless zone                   yellowish or white non-structured pattern                                   16
 Yellow and brown structureless zone                  yellow-brown pigmentation                                                   61
 Brown, gray, blue structureless zone                 diffuse hyperpigmentation                                                   16
 Structureless zone                                   obliteration of the pigmentary network                                      55
 Structureless zone                                   homogeneous cloud like pattern, homogenous cloud                            16
                                                      like pattern
 Brown structureless zone                             diffuse brown background, diffuse brown (brownish)                21,30,56,62
                                                      areas, diffuse brown colour, diffuse brownish
                                                      pigmentation
 Structureless zone                                   diffuse pigmentation                                                     29,56
 Gray, blue structureless zone                        gray-blue background                                                        47
 Brown structureless zone interrupted by              pseudonetwork, pseudoreticular pigmentary network,                   31,55,56
 follicular openings                                  pseudoreticular pigment network, pseudoreticular
                                                      pigmentary network pattern
 Blue, gray structureless zone interrupted by         blue-gray pigmentation around asymmetrically                                45
 follicular openings                                  distributed follicular openings
 Gray structureless zone                              gray blotch                                                                 30
 White structureless zone                             chalk-white structureless areas                                          14,22
 Brown, gray, black structureless zone                dark-coloured blotches                                                      63
 Red, brown structureless zone                        brown and erythematous homogeneous areas                                    12
WS = Wickham striae



of annular lichen planus, this variant may occur in other               commonly seen in Middle East, India and east Africa. Sites
regions as well. Dermatoscopic features of annular lichen               of involvement include sun-exposed areas [8].
planus may include circular WS, structureless zones with                   Güngör Ş et al analysed 255 lesions of active and regres-
different pigmentation, which has been described as ‘cloud-             sive LP and found that the course of the disease has an im-
like’, perifollicular-annu­
                          lar pigmentation, diffuse reticu­
                                                          lar           pact on the dermatoscopic appearance. WS are less common
pigmentation, as well as peripheral red dots on a pink back-            in acute lichen planus. Furthermore, acute LP is typified by
ground or erythema, which has been described as homo­                   the presence of vascular patterns and the absence of pig-
geneous vascular pattern [8,11,34].                                     ment patterns [11]. They also found that in regressive LP WS
    The dermatoscopic features of another type of LP, LP                and vascular patterns were absent while pigment patterns
actinicus, also known as LP tropicus, include diffuse pep­              were frequently seen. The different variants of pigmentation
pering pigment pattern on a brown background, without                   were described as peripheral dots, diffuse dots, perifollicular
WS or vascular patterns [8,11]. The skin lesions are most               -annular   pigmenta­
                                                                                           tion,    peripheral    peppering,   diffuse


Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                         7
    Figure 3. Plantar lichen planus. (A) Clinical presentation. (B) Dermatoscopic picture with typical reticular pattern and white scaling.




     Figure 4. Hypertrophic lichen planus. (A) Clinical (A) and (B) dermatoscopic images showing comedo-like structures filled with
     yellow keratinous plugs.




     Figure 5. Lichen planus pigmentosus. (A) Lichen planus pigmentosus in the groin of a patient with dark skin tone, clinical image.
     (B) Dermatoscopy shows brown dots in different arrangements. Wickham striae are absent.



openings. The furrows of the skin (skin markings) are not ex-                Annular LP is another rare variant of LP. Typically, the
posed to friction, which could be the reason for the absence             centre of the lesion is atrophic. Friedman and Hashimoto
of pigmentation in skin furrows in LPPI patients [11,12].                reported that the annular and central atrophy results from
Clinical and dermatoscopic images of LP pigmentosus are                  elastolytic activity of inflammatory cells. Although the geni-
shown in Figure 5.                                                       tal and intertriginous areas are common sites of involvement



8                                                                             Original article | Dermatol Pract Concept. 2023;13(3):e2023174
peppering, linear pig­mentation, cobblestone pigmentation,           basic elements lines, circles or ‘structureless’ if absence of
reticu­
      lar pigmentation, circular pigmentation, peripheral            basic elements. Due to the distinctiveness of the vocabulary
homogeneous cloud-like pigmentation, and diffuse homo-               describing vascular structures and limited vocabulary for de-
geneous cloud-like pigmentation. Furthermore, brown and              scribing scaling, we have listed terms and phrases describing
yellow background colours were also observed [11].                   vessels and scaling in a separate table (Table 3).
                                                                        This paper also demonstrates that the morphology of li-

Conclusions                                                          chen planus varies according to skin tone, duration, variants
                                                                     and anatomic site. Clinical and dermatoscopic images of LP
The increased use of dermatoscopy for inflammatory skin              in different stages in a patient with dark skin tone are shown
diseases resulted in an expansion of publications which              in Figure 6.
caused the dermatoscopic vocabulary to grow substantially.              The most consistent dermatoscopic feature of lichen pla-
LP is a particularly interesting example because it is equally       nus are WS. WS correspond to wedge-shaped hypergranu-
common among all ethnic groups and has a variable course.            losis in dermatopathology. They are mainly seen in active
The dermatoscopic features of LP vary significantly depend-          lesions of LP and can be regarded as an activation marker
ing on skin tone, course, variant, and anatomic site. These          of LP. WS may disappear after treatment, whereas pigment
idiosyncratic features of LP led researchers to use different        patterns resist treatment. In this regard it is important to
terms for the same structures, which is confusing and dimin-         emphasise the correlation between the dermatoscopic pat-
ishes the comparability between studies. Natural language            terns and the histological features of LP. Knowledge of
is expansive in nature and constantly creates new terms and          histopathology and its correlation with dermatoscopy in-
phrases, but this may not be desirable in science. Technical         creases the understanding of dermatoscopy and allows a
languages in- and outside of medicine typically limit their vo-      significant level of interpretation of dermatoscopic patterns
cabulary to a few, well defined standard terms. The same ap-         and clues [40].
proach is recommended in dermatoscopy. The standardized                 Pigment patterns on dermatoscopic examination corre-
terminology and standardized description suggested in the            spond to dermal melanophages and pigment incontinence
two consensus papers on dermatoscopic terminology [2,5]              and are a sign of regressing LP. It comes as no surprise that
will prevent the undesirable growth of terms. The first main         pigment patterns can be resistant to anti-inflammatory ther-
idea is to narrow down descriptions of dermatoscopic struc-          apy (e.g. topical steroids) due to the absence of the inflam-
tures to 3 basic elements: ‘lines’, ‘dots or clods’ and ‘circles’.   matory cells [11].
If none of these basic elements is present, the term ‘structure-        Dermatoscopy of LP may be used to assess the likelihood of
less’ can be applied [2]. This approach is sufficient to describe    the persistence of post-inflammatory hyperpigmentation. Struc-
even complex dermatoscopic structures [2]. The second idea           tureless light brown areas devoid of dots (granularity) are asso-
is to use a standardized way to describe non-neoplastic le-          ciated with a shorter duration and granular pigmentation being
sions including vessels, scales, follicular findings, other struc-   associated with a longer course. Furthermore, the dermatoscopy
tures and specific clues as put forward by Errichetti et al [5].     enables monitoring the evolution of lesions after therapy [3].
    Many articles included in this paper were published                 All those observations indicate the dynamic course of
before the consensus on dermatoscopic terminology for                LP and magnify the importance and the advantages of der-
non-neoplastic skin diseases. Lack of guidelines resulted it in      matoscopy. It can be helpful not only for the diagnosis but
a wild growth of terminology for a single disease. We were           also for treatment decisions and prognosis. A limitation of
able to identify 118 terms and phrases for LP. This is clearly       this paper is that we did not include dermatoscopic fea-
too much. Some terms and phrases describe the same struc-            tures of non-cutaneous LP (nails, hair, mucosa), which have
tures in different words, for example ‘white crossing lines’,        their own descriptions. According to the level of evidence
‘cross-linked WS’, ‘white crossing streaks’, ‘reticular pearly       majority of works are level 4 (case series, low-quality co-
white areas’ [2,16,35-39]. These abundant number of terms            hort or case-control studies) or 5 (expert opinions based on
for basically the same structure have no additional value and        non-systematic reviews of results or mechanistic studies). The
it is better to use just one term, either reticular white lines or   intent of this critical paper is not to discourage researchers
simply Wickham striae – a specific clue [2].                         from making new observations and describing them in their
    The largest numbers of terms and phrases used for der-           own words. On the contrary, we want to support researchers
matoscopic features of LP were those addressing manifesta-           by giving them a framework in which their astute observa-
tions of patterns formed by Wickham striae and clods and             tions can be described in a meaningful and repeatable way so
dots. We have summarized the terms found in the literature           that others can benefit maximally from their findings.
in Table 2. Here, we also tried to translate the remaining              It should be noted that in many cases of LP the diagnosis
terms or phrases into a standardized terminology using the           can be established easily with the unaided eye. However, if



Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                        9
     Table 3. Lichen planus metaphoris presented in literature vs. suggested descriptive terminology
                                         (scaling and vessels).
                                                                                                                References # (where
          Descriptive terminology                               Metaphoric terminology                              mentioned)
                                                                  Scaling
 White scale                                       chalk-like scale                                                           22,27
 White scale                                       white scales; distribution: diffuse, patchy,                       20,39,48,56
                                                   peripheral
 White scale with a central distribution           whitish scaly plaques                                                         17
 White scale                                       overlying white scales                                                        24
 White reticular scaly lines                       a lacy network of white scales                                                  7
 Yellow scale                                      yellowish scales                                                       36,39,43
                                                                 VESSELS
 Red structureless zone                            peripheral homogen vascular pattern                                           11
 Clustered vessels                                 pattern of vessels: patchy, peripheral;                                   39, 48
                                                   patchy vessels
 Pink structureless zone or simply                 light red background                                                          47
 erythema




   Figure 6. Lichen planus in different stages. (A) Lichen planus in a patient with dark skin tone, clinical image (A). (B) Dermatoscopy
   shows prominent white lines (Wickham striae) and keratin plugs that appear as yellow clods. The flat pigmented lesions are older
   lesions with pigmented dots, circles, lines and dots ranged in circles. These structures received many different and colourful names in
   the literature.



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in a diagnostic process of this inflammatory skin disease [16].             Dermoscopy. J Am Acad Dermatol. 2016;74(6):1093-1106.
                                                                            DOI:10.1016/j.jaad.2015.12.038. PMID: 26896294. PMCID:
In doubtful cases the gold standard for the diagnosis is still
                                                                            PMC5551974.
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Original article | Dermatol Pract Concept. 2023;13(3):e2023174                                                                           13
