10.5826/dpc.1401a40
Introduction: Dermoscopic findings are used to diagnose and evaluate disease activity in patients with cutaneous lupus erythematosus (CLE).
Objectives: This study aimed to characterize the dermoscopic features of discoid LE (DLE) and LE tumidus (LET) by lesion duration and CLE Disease Area and Severity Index (CLASI) scores and to examine the dermoscopic findings of lesions in different locations in DLE patients.
Methods: Dermoscopic findings (follicular features, perifollicular surface, interfollicular features, and vessel pattern) were assessed and lesion duration (≤12 and &gt;12 months) and CLASI scores (grouped as mild or moderate) were calculated. DLE lesion locations were categorized as, non-scalp, scalp and lip.
Results: Forty-eight dermoscopic images from 35 DLE and 4 LET patients were analyzed.  The most common dermoscopic findings in non-scalp DLE were follicular keratotic plugs (82.8%) and white scales (69%). In scalp DLE (n=9), the most common findings were absent follicular openings (77.8%), white structureless areas (77.8%), and perifollicular scaling (66.7%). All LET patients had pink-white background and linear vessels. Follicular plugs, peripheral pigmentation, and polymorphous vessels were lower in patients with mild CLASI activity than moderate activity (P = 0.036, 0.039, and 0.019, respectively). Fibrotic white dots, honeycomb pigment pattern, and blue-gray dots/globules were lower in those with mild CLASI damage scores than moderate damage (P = 0.010, 0.010, and 0.020, respectively). Peripheral pigmentation was more common in patients with lesion duration ≤12 months, while blue-gray dots/globules were more common with lesion durations &gt;12 months.
Conclusions: Certain dermoscopic features may facilitate the differential diagnosis of DLE and LET.
text/xml
2160-9381
3398
en
Mehmet Şerif Danışman
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
cutaneous lupus erythematosus disease area and severity index (CLASI)
Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2024-01-31
2023-04-05
2024-01-31
2024-02-21
e2024040
Dermatol Pract Concept
Introduction: Dermoscopic findings are used to diagnose and evaluate disease activity in patients with cutaneous lupus erythematosus (CLE).
Objectives: This study aimed to characterize the dermoscopic features of discoid LE (DLE) and LE tumidus (LET) by lesion duration and CLE Disease Area and Severity Index (CLASI) scores and to examine the dermoscopic findings of lesions in different locations in DLE patients.
Methods: Dermoscopic findings (follicular features, perifollicular surface, interfollicular features, and vessel pattern) were assessed and lesion duration (≤12 and &gt;12 months) and CLASI scores (grouped as mild or moderate) were calculated. DLE lesion locations were categorized as, non-scalp, scalp and lip.
Results: Forty-eight dermoscopic images from 35 DLE and 4 LET patients were analyzed.  The most common dermoscopic findings in non-scalp DLE were follicular keratotic plugs (82.8%) and white scales (69%). In scalp DLE (n=9), the most common findings were absent follicular openings (77.8%), white structureless areas (77.8%), and perifollicular scaling (66.7%). All LET patients had pink-white background and linear vessels. Follicular plugs, peripheral pigmentation, and polymorphous vessels were lower in patients with mild CLASI activity than moderate activity (P = 0.036, 0.039, and 0.019, respectively). Fibrotic white dots, honeycomb pigment pattern, and blue-gray dots/globules were lower in those with mild CLASI damage scores than moderate damage (P = 0.010, 0.010, and 0.020, respectively). Peripheral pigmentation was more common in patients with lesion duration ≤12 months, while blue-gray dots/globules were more common with lesion durations &gt;12 months.
Conclusions: Certain dermoscopic features may facilitate the differential diagnosis of DLE and LET.
Mehmet Şerif Danışman
2024/01/31
10.5826/dpc.1401a40
e2024040
Departments of Dermatology and Venereology, Faculty of Medicine, Trakya University, Edirne, Turkey
2160-9381
cutaneous lupus erythematosus disease area and severity index (CLASI)
en
e2024040
Kuhn A, Meuth AM, Bein D, et al. Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus. Br J Dermatol. 2010;163(1):83-92. DOI:10.1111/j.1365-2133.2010.09799.x. PMID: 20394621.
Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score
https://dpcj.org/index.php/dpc/article/download/3398/2434
    Dermoscopic Characteristics of Cutaneous Lupus
      Erythematosus According to Subtype, Lesion
       Location, Lesion Duration, and CLASI Score
                       Yıldız Gürsel Ürün1, Mustafa Ürün1, Mehmet Şerif Danişman1


1 Departments of Dermatology and Venereology, Faculty of Medicine, Trakya University, Edirne, Turkey



Key words: discoid lupus erythematosus, dermoscopy, lupus erythematosus tumidus, cutaneous lupus erythematosus disease area and
severity index
Citation: Gürsel Ürün Y, Ürün M, Danişman MS. Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype,
Lesion Location, Lesion Duration, and CLASI Score. Dermatol Pract Concept. 2024;14(1):e2024040. DOI: https://doi.org/10.5826
/dpc.1401a40
Accepted: June 9, 2023; Published: January 2024
Copyright: ©2024 Gürsel Ürün et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Dr. Yıldız Gürsel Ürün, Department of Dermatology and Venereology, Faculty of Medicine, Trakya University,
Edirne/Turkey. Tel: +90 284 235 7641 / +90 505 537 30 63 Email: yildizgurselurun@trakya.edu.tr




  ABSTRACT             Introduction: Dermoscopic findings are used to diagnose and evaluate disease activity in patients with
                       cutaneous lupus erythematosus (CLE).
                       Objectives: This study aimed to characterize the dermoscopic features of discoid LE (DLE) and
                       LE tumidus (LET) by lesion duration and CLE Disease Area and Severity Index (CLASI) scores and to
                       examine the dermoscopic findings of lesions in different locations in DLE patients.
                       Methods: Dermoscopic findings (follicular features, perifollicular surface, interfollicular features, and
                       vessel pattern) were assessed and lesion duration (≤12 and >12 months) and CLASI scores (grouped as
                       mild or moderate) were calculated. DLE lesion locations were categorized as, non-scalp, scalp and lip.
                       Results: Forty-eight dermoscopic images from 35 DLE and 4 LET patients were analyzed. The most
                       common dermoscopic findings in non-scalp DLE were follicular keratotic plugs (82.8%) and white
                       scales (69%). In scalp DLE (n=9), the most common findings were absent follicular openings (77.8%),
                       white structureless areas (77.8%), and perifollicular scaling (66.7%). All LET patients had pink-white
                       background and linear vessels. Follicular plugs, peripheral pigmentation, and polymorphous vessels
                       were lower in patients with mild CLASI activity than moderate activity (P = 0.036, 0.039, and 0.019,
                       respectively). Fibrotic white dots, honeycomb pigment pattern, and blue-gray dots/globules were lower
                       in those with mild CLASI damage scores than moderate damage (P = 0.010, 0.010, and 0.020, respec-
                       tively). Peripheral pigmentation was more common in patients with lesion duration ≤12 months, while
                       blue-gray dots/globules were more common with lesion durations >12 months.
                       Conclusions: Certain dermoscopic features may facilitate the differential diagnosis of DLE and LET.



Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                        1
Introduction                                                     age at onset, duration and location of lesions, F
                                                                                                                 ­ itzpatrick
                                                                 skin type, topical and systemic treatments received, and an-
Discoid lupus erythematosus (DLE) is the most common             tinuclear antibody [ANA] positivity) were retrospectively
type of cutaneous lupus erythematosus (CLE) [1]. DLE is          screened by an independent dermatologist (MŞD). Exclusion
defined as a subtype of chronic CLE (CCLE) and is cate-          criteria were: 1) age younger than 18 years, 2) lack of de-
gorized as one of the specific skin manifestations of lupus      finitive diagnosis, 3) diagnosis of overlap syndrome/mixed
erythematosus [2,3]. Lupus erythematosus tumidus (LET),          connective tissue disease, and 4) receiving topical and/or sys-
the most photosensitive type of lupus erythematosus, was         temic treatment in the last 3 months [13,14].
recently classified separately as intermittent CLE (ICLE) [4].      Cutaneous Lupus Erythematosus Disease Area and Sever-
    DLE heals with scarring and dyspigmentation, and se-         ity Index Activity (CLASI-A) and CLASI Damage (CLASI-D)
vere inflammatory DLE impacts patients’ quality of life          scores were calculated at initial presentation by a different der-
[5-7]. The differential diagnosis of DLE includes many dis-      matologist (MÜ). Clinical and dermoscopic lesion locations
eases, and early treatment leads to complete clearance of        were determined according to the CLASI classification [15].
active lesions [8,9]. For patients with CLE, using the CLE       CLASI-A scores were grouped into disease activity levels of
Disease Area and Severity Index (CLASI) is recommended at        mild (0-9), moderate (10-20), and severe (21-70) as recom-
baseline, while monitoring treatment response, and in the as-    mended by Klein et al [16]. CLASI-D scores were grouped
sessment of the disease impact on quality of life [7,8]. CLASI   into disease severity levels of mild (0-5), moderate (6-16),
is used in most CLE patients, with the exception of a few        and severe (≥17) [17].
rare subtypes [10].                                                 Dermoscopic images were divided into three regions
    Dermoscopy of inflammatory dermatoses, also known as         (non-scalp, scalp, and lip [cutaneous and/or mucosal]) by an
inflammascopy, has become an important tool not only for         independent dermatologist (MÜ). Lesions on the rest of the
diagnosis but also for evaluating disease activity [11]. Au-     face, ears, back, nose, chest, arms were included in the non-
thors recommend using dermoscopic findings from inflam-          scalp category [18]. CLASI-A and D scores were calculated
mascopy examination along with a patient’s history, clinical     separately for each location (non-scalp, scalp, and lip).
picture, and macroscopic features [12]. In this respect, it is      All dermoscopic findings were evaluated at 20X mag-
important to know the dermoscopic characteristics in differ-     nification with a video dermoscope (FotoFinder Systems
ent locations.                                                   GmbH) by the same dermatologist (YGÜ), who was blinded
                                                                 to the patients macroscopic photographs and lesion loca-
                                                                 tions. Both “dry” (without immersion fluid) and “wet” (with
Objectives
                                                                 ultrasound gel) dermoscopy was performed. During the pro-
This study aimed to evaluate the dermoscopic findings of         cedures, minimal pressure was applied for better visualiza-
patients with DLE and LET and summarize the dermoscopic          tion of blood vessels.
features of DLE lesions in various anatomical locations. We         Using a review by Zychowska et al. as a reference, der-
also aimed to evaluate differences in the dermoscopic find-      moscopic images were examined under four main headings: :
ings of patients with CLE according to lesion duration and       1) follicular features (Figure 1A-I), 2) interfollicular features
CLASI scores. Thus, having more detailed knowledge of der-       (Figure 2A-F, Figure 3A-D), 3) perifollicular surface (Figure
moscopic findings will guide clinicians in the diagnosis and     4A-D), and 4) vessel pattern (Figure 5A-E) [18]. In this study,
follow-up of patients with DLE and LET.                          the appearance of arborizing vessels was described as similar
                                                                 to the dermoscopic appearance of vessels in basal cell carci-
                                                                 noma but thicker and irregular. The study by Lallas et al was
Methods                                                          used for the description of thin and linear vessels (with and
This study was planned as a retrospective cohort study in-       without bends or branches) [19]. The vessel patterns in our
cluding patients diagnosed with DLE and LET who pre-             study were evaluated as recommended by Lallas et al. The
sented to the Skin and Venereal Diseases outpatient clinic of    standardized dermoscopic terms for non-neoplastic derma-
Trakya University between 2018 and 2022. Approval was            toses published by Errichetti et al were used to describe the
obtained from the Trakya University Faculty of Medicine          dermoscopic images [20].
Ethics Committee (2023/69).
    Patients diagnosed with DLE or LET whose medical re-         Statistical Analysis
cords contained complete clinical, histopathological, and di-    The data were analyzed using SPSS (Statistical Package for
rect immunofluorescence data were included in the study. The     Social Sciences) version 18.0. In descriptive analyses, fre-
patients sociodemographic and clinical characteristics (age,     quency data were expressed as number (N) and percentage
sex, tobacco and alcohol use, family history, CLE subtype,       (%), and numerical data were presented as mean, standard



2                                                                    Original Article | Dermatol Pract Concept. 2024;14(1):e2024040
deviation (SD), and range (minimum-maximum). The dis-              not detected in any of the lesions involving the lips but were
tribution of categorical data was analyzed using the Fisher        observed at high rates in the other groups (Table 1).
exact test. Level of statistical significance was accepted as          Distributions of dermoscopic features according to lesion
p<0.05 for all tests.                                              locations in patients with DLE are compared in ­Table 2. Pa-
                                                                   tients with scalp DLE had significantly higher rates of absence
                                                                   of follicular openings and perifollicular scaling compared to
Results                                                            patients with non-scalp DLE (P values <0.001 and 0.009,
                                                                   respectively). Dermoscopic images with follicular plugs
Demographic and Clinical Characteristics
                                                                   (P < 0.001) and perifollicular white color (P = 0.027) were
A total of 39 CLE patients with 48 dermoscopic images              statistically less common in DLE patients with lip location
were included in the study. The mean age of the patients was       than in patients with non-scalp location. In the lip location
43.95 ± 12.61 years and 71.8% (N = 28) were women. CLE             group, yellow (scales and crusts) (P = 0.016) and hairpin
type was DLE in 35 patients (89.7%) and LET in 4 patients          vessels (P < 0.001) were more common while dotted vessels
(10.3%). Most CLE lesions were located on the rest of the face     (P = 0.022) and linear vessels (P = 0.019) were less com-
(58.9%) and on the scalp (23%). Lip location was most fre-         mon compared to patients with non-scalp location (­Table 2).
quently associated with lesions on the rest of the face (N = 4);   When grouped and compared according to CLASI-A scores,
isolated lip location was observed in only one patient. In         patients with mild disease activity had significantly lower
the LET group, dermoscopic images were obtained from the           rates of follicular plugs, peripheral pigmentation, and poly-
back in 3 patients and the chest in 1 patient. Thirty (76.9%)      morphous vessels compared to those with moderate disease
of the patients received topical corticosteroids and 36 (92.3%)    activity (P values 0.036, 0.039, and 0.019, respectively).
received hydroxychloroquine therapy (Table S1).                    There was no statistical difference in the distribution of
                                                                   other dermoscopic features between the mild and moderate
Distribution of Dermoscopic Images                                 activity groups (P > 0.05) (Table 3).
The dermoscopic images were most commonly from the rest                When grouped and compared according to CLASI-D
of the face (45.8%, N = 22 images), scalp (18.7%, N = 9            scores, rates of fibrotic white dots, honeycomb pigment pat-
images), lips (12.5%, N = 6 images), and ears (8.3%, N = 4         tern, and blue-gray dots/globules were found to be signifi-
images) (Table S2).                                                cantly lower in patients with mild disease severity compared
                                                                   to those with moderate disease severity (P values 0.010,
CLASI Scores                                                       0.010, and 0.020, respectively). There was no statistical dif-
The mean CLASI-A score was 5.23 ± 3.44 and the mean                ference in the distribution of other dermoscopic features be-
CLASI-D score was 2.52 ± 2.83 (Table S1).                          tween the disease severity groups (P > 0.05) (Table 4).
                                                                       When differences in the dermoscopic findings of pa-
Dermoscopic Findings                                               tients with CLE were evaluated according to lesion duration
The most common dermoscopic findings in DLE patients               (≤12 versus. >12 months), we observed that blue-gray dots/
were white structureless areas (70.5% of images), follicular       globules, and dotted vessels were more common dermoscopic
plugs (65.9%), white scales (63.6%), pink-white background         findings in patients with lesion duration over 12 months
(56.8%), and linear vessels (50%). In patients with LET,           (P values 0.018 and 0.021, respectively) (Table 5).
the most common dermoscopic findings were pink-white
background (100%) and linear vessels (100%). Among
                                                                   Conclusions
DLE patients with scalp location, the most common dermo-
scopic findings were absence of follicular openings (77.8%)        The sociodemographic characteristics of our study sample
white structureless areas (77.8%), and perifollicular scaling      (age, sex, age at onset) were similar to those in other studies [7].
(66.7%).                                                           Fredeau et al reported that 73% of patients had a Fitzpatrick
    The most common vessel patterns observed in all pa-            skin type between I and IV [21]. In our study, Fitzpatrick skin
tients were linear vessels (54.2%, N = 26 of images) and           types ranged from II to IV. Although it is known that the in-
dotted vessels (33.7%, N = 18 of images). Follicular plugs         cidence of LE is higher in Asian and black ethnic groups than
were observed in 69.6% (N = 32) of all lesions but were not        in whites, ethnic background was not evaluated in our study.
detected in any of the lesions involving the lips. White struc-        Insawang et al reported that the most common lesion lo-
tureless areas and hairpin vessels were present in all lesions     cations in patients with DLE were the face and scalp [22].
involving the lips and were less frequent in the other groups.     Between 25% and 90% of patients with DLE are photosen-
Perifollicular scaling and perifollicular pigmentation were        sitive, and apoptosis and other immunological mechanisms
                                                                   induced by UV light lead to more frequent manifestations of



Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                       3
              Table 1. Dermoscopic characteristics in all patients and according to disease subtype
                                            and lesion locations.
                                                  All             DLEa                LET            Scalp DLE          Lips DLE
             Dermoscopic features               (N = 48)        (N = 44)            (N = 4)           (N = 9)            (N = 6)
    Follicular features, N (%)
    Follicular plugs                           30 (62.5)        29 (65.9)          1 (25.0)           5 (55.6)         0 (0.0)
    Absence of follicular openings              9 (18.8)         9 (20.5)          0 (0.0)            7 (77.8)         0 (0.0)
    Reduced number of follicular openings       3 (6.3)          3 (6.8)           0 (0.0)            0 (0.0)          0 (0.0)
    Fibrotic white dots                         8 (16.7)         8 (18.2)          0 (0.0)            4 (44.4)         0 (0.0)
    Pinpoint white dots                         6 (12.5)         6 (13.6)          0 (0.0)            0 (0.0)          0 (0.0)
    Follicular red dots                         5 (10.4)         5 (11.3)          0 (0.0)            3 (33.3)         0 (0.0)
    Yellow dots                                 2 (4.2)          2 (4.5)           0 (0.0)            0 (0.0)          0 (0.0)
    Black dots                                  4 (8.3)          4 (9.1)           0 (0.0)            2 (22.2)         0 (0.0)
    Red spider on a yellow dot                  1 (2.1)          0 (0.0)           1 (25.0)           0 (0.0)          0 (0.0)
    Dilated follicles                           3 (6.3)          3 (6.8)           0 (0.0)            1 (11.1)         0 (0.0)
    Perifollicular surface, N (%)
    Perifollicular white color                 19 (39.6)        19 (43.2)          0 (0.0)            4 (44.4)         0 (0.0)
    Perifollicular scaling                     13 (27.1)        11 (25.0)          0 (0.0)            6 (66.7)         0 (0.0)
    Perifollicular erythema                     3 (6.3)          3 (6.8)           0 (0.0)            0 (0.0)          0 (0.0)
    Perifollicular pigmentation                13 (27.1)        13 (29.6)          0 (0.0)            3 (33.3)         0 (0.0)
    Interfollicular features, N (%)
    White structureless areas                  32 (66.7)        31 (70.5)          1 (25.0)           7 (77.8)         6 (100.0)
    Pink-white background                      29 (60.4)        25 (56.8)          4 (100.0)          2 (22.2)         4 (66.7)
    Speckled brown pigmentation                14 (29.2)        14 (31.8)          0 (0.0)            2 (22.2)         0 (0.0)
    Honeycomb pigment pattern                   3 (6.3)          3 (6.8)           0 (0.0)            1 (11.1)         0 (0.0)
    Peripheral pigmentation                    11 (22.9)        11 (25.0)          0 (0.0)            1 (11.1)         0 (0.0)
    White scales                               30 (62.5)        28 (63.6)          2 (50.0)           3 (33.3)         5 (83.3)
    Yellow (scales and crusts)                 10 (20.8)        10 (22.7)          0 (0.0)            3 (33.3)         4 (66.7)
    White rosettes                              7 (14.6)         7 (15.9)          0 (0.0)            1 (11.1)         1 (16.7)
    Shiny white lines                           9 (18.8)         8 (18.2)          1 (25.0)           0 (0.0)          3 (50.0)
    Blue-gray dots/globules                     9 (18.8)         9 (20.5)          0 (0.0)            0 (0.0)          0 (0.0)
    Blue-white veil                             0 (0.0)          0 (0.0)           0 (0.0)            0 (0.0)          0 (0.0)
    Erosions/ulcerations                       10 (20.8)        10 (22.7)          0 (0.0)            2 (22.2)         3 (50.0)
    Vessel pattern, N (%)
    Thick arborizing vessels                    9 (18.8)         9 (20.5)          0 (0.0)            4 (44.4)         0 (0.0)
    Dotted vessels                             18 (33.7)        16 (36.3)          2 (50.0)           0 (0.0)          0 (0.0)
    Hairpin vessels                             8 (16.7)         8 (18.2)          0 (0.0)            0 (0.0)          6 (100.0)
    Linear vessels                             26 (54.2)        22 (50.0)          4 (100.0)          5 (55.6)         0 (0.0)
    Coiled vessels                              0 (0.0)          0 (0.0)           0 (0.0)            0 (0.0)          0 (0.0)
    Polymorphous vessels                        2 (4.2)          2 (4.5)           0 (0.0)            0 (0.0)          0 (0.0)

DLE = Discoid lupus erythematosus; LET = Lupus erythematosus tumidus.
a
   The DLE category includes dermoscopic images obtained from patients clinically and histopathologically diagnosed with DLE who
­presented with non-scalp (rest of the face, ears, back, nose, chest, arms), scalp, and lip location.




the disease in sun-exposed areas [23]. Our findings in this       perifollicular white color, and white scales [18,19,24]. Our
study are consistent with this.                                   dermoscopic findings are similar to those of other studies.
      The most common dermoscopic findings in DLE pa-                   Lallas et al reported that telangiectasias were the most
tients with non-scalp lesion locations are follicular plugs,      common vessel pattern in DLE [19]. In another study, the most



4                                                                       Original Article | Dermatol Pract Concept. 2024;14(1):e2024040
       Table 2. Comparison of dermoscopic findings according to non-scalp, scalp and lip location in
                  patients with discoid lupus erythematosus (N = 35 patients, 44 images).
                                                                         DLE                                            DLE
                                                                    a                                              a
                                                      Non-scalp            Scalp           P         Non-scalp            Lip            P
             Dermoscopic features                      (N = 29)           (N = 9)        valueb       (N = 29)          (N = 6)        valueb
    Follicular features, N (%)
    Follicular plugs                                   24 (82.8)          5 (55.6)        0.174       24 (82.8)         0 (0)          ˂0.001
    Absence of follicular openings                       2 (6.9)          7 (77.8)       ˂0.001         2 (6.9)         0 (0)           1.000
    Reduced number of follicular openings                3 (10.3)         0 (0)           1.000         3 (10.3)        0 (0)           1.000
    Fibrotic white dots                                  4 (13.8)         4 (44.4)        0.071         4 (13.8)        0 (0)           1.000
    Pinpoint white dots                                  6 (20.7)         0 (0)           0.303         6 (20.7)        0 (0)           0.561
    Follicular red dots                                  2 (6.9)          3 (33.3)        0.075         2 (6.9)         0 (0)           1.000
    Yellow dots                                          1 (3.4)          0 (0)           1.000         1 (3.4)         1 (16.7)        0.318
    Black dots                                           2 (6.9)          2 (22.2)        0.233         2 (6.9)         0 (0)           1.000
    Dilated follicles                                    2 (6.9)          1 (11.1)        1.000         2 (6.9)         0 (0)           1.000
    Perifollicular surface, N (%)
    Perifollicular white color                          15 (51.7)         4 (44.4)        1.000       15 (51.7)         0 (0)           0.027
    Perifollicular scaling                               5 (17.2)         6 (66.7)        0.009         5 (17.2)        0 (0)           0.561
    Perifollicular erythema                              3 (10.3)         0 (0)           1.000         3 (10.3)        0 (0)           1.000
    Perifollicular pigmentation                         10 (34.5)         3 (33.3)        1.000       10 (34.5)         0 (0)           0.152
    Interfollicular features, N (%)
    White structureless areas                           18 (62.1)         7 (77.8)        0.456       18 (62.1)         6 (100.0)       0.146
    Pink-white background                               19 (65.5)         2 (22.2)        0.051       19 (65.5)         4 (66.7)        1.000
    Speckled brown pigmentation                         12 (41.4)         2 (22.2)        0.438       12 (41.4)         0 (0)           0.074
    Honeycomb pigment pattern                            2 (6.9)          1 (11.1)        1.000         2 (6.9)         0 (0)           1.000
    Peripheral pigmentation                             10 (34.5)         1 (11.1)        0.237       10 (34.5)         0 (0)           0.152
    White scales                                        20 (69)           3 (33.3)        0.115       20 (69)           5 (83.3)        0.649
    Yellow (scales and crusts)                           4 (13.8)         3 (33.3)        0.322         4 (13.8)         4(66.7)        0.016
    White rosettes                                       5 (17.2)         1 (11.1)        1.000         5 (17.2)        1 (16.7)        1.000
    Shiny white lines                                    6 (20.7)         0 (0)           0.303         6 (20.7)        3 (50.0)        0.602
    Blue-gray dots/globules                              9 (31)           0 (0)           0.082         9 (31)          0 (0)           0.304
    Erosions/ulcerations                                 6 (20.7)         2 (22.2)        1.000         6 (20.7)        3 (50.0)        0.602
    Vessel pattern, N (%)
    Thick arborizing vessels                             6 (20.7)         3 (33.3)        0.655         7 (24.1)        0 (0)           0.311
    Dotted vessels                                      16 (55.2)         0 (0)           0.005       16 (55.2)         0 (0)           0.022
    Hairpin vessels                                      3 (10.3)         0 (0)           1.000         3 (10.3)        6 (100.0)       0.001
    Linear vessels                                      17 (58.6)         5 (55.6)        1.000       17 (58.6)         0 (0)           0.019
    Polymorphous vessels                                 2 (6.9)          0 (0)           1.000         2 (6.9)         0 (0)           1.000

DLE= Discoid lupus erythematosus.
a
    Dermoscopic images of the rest of the face, ears, nose, chest, back, and arms were included in the non-scalp group. b Fisher exact test.




common vessel pattern in patients with DLE was reported                     openings, and perifollicular scaling [18,33] The prevalence
to be polymorphous, linear and linear curved vessels [25].                  of these findings was significantly higher for patients with
Thus, considering the literature and our study, linear vessels              scalp lesion locations compared to patients with non-scalp
are more common in DLE with non-scalp lesion locations                      lesion locations [18]. Our findings are consistent with the lit-
[18,24,26,27].                                                              erature. Absent follicular openings and perifollicular scaling
      The most common dermoscopic findings in scalp DLE                     in particular should be kept in mind as important dermo-
include white structureless areas, absence of follicular                    scopic findings in DLE scalp location.



Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                                  5
                   Table 3. Dermoscopic characteristics according to CLASI activity score groups.
                                                                   CLASI activity score
                  Dermoscopic features                    Mild (N = 41)            Moderate (N = 7)                 P valuea
    Follicular features, N (%)
    Follicular plugs                                        26 (56.1)                   7 (100.0)                     0.036
    Absence of follicular openings                            8 (19.5)                  1 (14.3)                      1.000
    Reduced number of follicular openings                     3 (7.3)                   0 (0.0)                       1.000
    Fibrotic white dots                                       7 (17.1)                  1 (14.3)                      1.000
    Pinpoint white dots                                       5 (12.2)                  1 (14.3)                      1.000
    Follicular red dots                                       3 (7.3)                   2 (28.6)                      0.148
    Yellow dots                                               2 (4.9)                   0 (0.0)                       1.000
    Black dots                                                4 (9.8)                   0 (0.0)                       1.000
    Red spider on a yellow dot                                1 (2.4)                   0 (0.0)                       1.000
    Dilated follicles                                         2 (4.9)                   1 (14.3)                      0.384
    Perifollicular surface, N (%)
    Perifollicular white color                              14 (34.1)                   5 (71.4)                      0.097
    Perifollicular scaling                                  11 (26.8)                   2 (28.6)                      1.000
    Perifollicular erythema                                   2 (4.9)                   1 (14.3)                      0.384
    Perifollicular pigmentation                             10 (24.4)                   3 (42.9)                      0.370
    Interfollicular features, N (%)
    White structureless areas                               26 (63.4)                   6 (85.7)                      0.398
    Pink-white background                                   23 (56.1)                   6 (85.7)                      0.219
    Speckled brown pigmentation                             11 (26.8)                   3 (42.9)                      0.400
    Honeycomb pigment pattern                                 1 (2.4)                   2 (28.6)                      0.052
    Peripheral pigmentation                                   7 (17.1)                  4 (57.1)                      0.039
    White scales                                            25 (61.0)                   5 (71.4)                      0.696
    Yellow (scales and crusts)                                7 (17.1)                  3 (42.9)                      0.147
    White rosettes                                            6 (14.6)                  1 (14.3)                      1.000
    Shiny white lines                                         7 (17.1)                  2 (28.6)                      0.601
    Blue-gray dots/globules                                   6 (14.6)                  3 (42.9)                      0.111
    Erosions/ulcerations                                    10 (24.4)                   0 (0.0)                       0.318
    Vessel pattern, N (%)
    Thick Arborizing vessels                                  7 (17.1)                  2 (28.6)                      0.601
    Dotted vessels                                          16 (39.0)                   4 (57.1)                      0.429
    Hairpin vessels                                           6 (14.6)                  2 (28.6)                      0.330
    Linear vessels                                          22 (53.7)                   4 (57.1)                      1.000
    Polymorphous vessels                                      0 (0.0)                   2 (28.6)                      0.019

CLASI = Cutaneous Lupus Erythematosus Disease Area and Severity Index.
a
Fisher exact test



      Distinguishing between scalp DLE and lichen planopi-               The term “thick arborizing vessels” is used more often
laris can be difficult in clinical practice [32]. According to    when evaluating dermoscopic findings in DLE patients with
Shim et al., the main criterion distinguishing DLE is the         scalp location [27-30]. Gomez-Quispe et al. suggested that the
presence of follicular plugs [35]. In our study, the prevalence   term “thick vessels” should be evaluated relative to the thick-
of follicular plugs was 55.6%, similar to the literature. Al-     ness of the hair shaft [31]. The second most common vessel
though the dermoscopic finding of follicular plugs is not as      pattern in scalp DLE patients in our study was “thick arboriz-
common in scalp DLE as in non-scalp DLE patients, it is           ing vessels”. However, we did not evaluate the vessels relative
highly diagnostic [33].                                           to the thickness of the hair shaft. It is clear that there is still a



6                                                                        Original Article | Dermatol Pract Concept. 2024;14(1):e2024040
                  Table 4. Dermoscopic characteristics according to CLASI damage score groups.
                                                                         CLASI damage score
                   Dermoscopic features                          Mild (N = 37)         Moderate (N = 11)             P valuea
    Follicular features, N (%)
    Follicular plugs                                               21 (56.8)                 9 (81.8)                  0.171
    Absence of follicular openings                                  5 (13.5)                 4 (36.4)                  0.180
    Reduced number of follicular openings                           1 (2.7)                  2 (18.2)                  0.127
    Fibrotic white dots                                             3 (8.1)                  5 (45.5)                  0.010
    Pinpoint white dots                                             4 (10.8)                 2 (18.2)                  0.609
    Follicular red dots                                             2 (5.4)                  3 (27.3)                  0.072
    Yellow dots                                                     2 (5.4)                  0 (0.0)                   1.000
    Black dots                                                      3 (8.1)                  1 (9.1)                   1.000
    Red spider on a yellow dot                                      1 (2.7)                  0 (0.0)                   1.000
    Dilated follicles                                               2 (5.4)                  1 (9.1)                   0.551
    Perifollicular surface; N (%)
    Perifollicular white color                                     13 (35.1)                 6 (54.5)                  0.304
    Perifollicular scaling                                         10 (27.0)                 3 (27.3)                  1.000
    Perifollicular erythema                                         2 (5.4)                  1 (9.1)                   0.551
    Perifollicular pigmentation                                     9 (24.3)                 4 (36.4)                  0.458
    Interfollicular features, N (%)
    White structureless areas                                      22 (59.5)                10 (90.9)                  0.073
    Pink-white background                                          24 (64.9)                 5 (45.5)                  0.304
    Speckled brown pigmentation                                    10 (27.0)                 4 (36.4)                  0.708
    Honeycomb pigment pattern                                       0 (0.0)                  3 (27.3)                  0.010
    Peripheral pigmentation                                         9 (24.3)                 2 (18.2)                  1.000
    White scales                                                   23 (62.2)                 7 (63.6)                  1.000
    Yellow (scales and crusts)                                      7 (18.9)                 3 (27.3)                  0.675
    White rosettes                                                  5 (13.5)                 2 (18.2)                  0.653
    Shiny white lines                                               7 (18.9)                 2 (18.2)                  1.000
    Blue-gray dots/globules                                         4 (10.8)                 5 (45.5)                  0.020
    Erosions/ulcerations                                            7 (18.9)                 3 (27.3)                  0.675
    Vessel pattern, N (%)
    Thick Arborizing vessels                                        6 (16.2)                 3 (27.3)                  0.409
    Dotted vessels                                                 14 (37.8)                 6 (54.5)                  0.488
    Hairpin vessels                                                 7 (18.9)                 1 (9.1)                   0.661
    Linear vessels                                                 20 (54.1)                 6 (54.5)                  1.000
    Polymorphous vessels                                            1 (2.7)                  1 (9.1)                   0.410

CLASI = Cutaneous Lupus Erythematosus Disease Area and Severity Index.
a
Fisher exact test



lack of standardization for dermoscopic terms used to describe          fibrosis and although it can be seen in both scalp and non-
vessel patterns, and further studies on this subject are needed.        scalp location, it aids in the diagnosis of scalp DLE.
      The dermoscopic appearance of “white perifollicular                      In our study, the second most common vessel pattern
color” has rarely been reported in DLE patients with scalp              observed in patients with non-scalp DLE was observed to
location [28,36]. Golińska et al emphasized that this dermo-            be “dotted vessels.” Non-follicular red dots are considered
scopic finding had 100% specificity for DLE with scalp lo-              “dotted vessels” [18]. The dotted vessel pattern is mostly
cation [32]. In our study, it was observed in 44.4% of scalp            seen in subacute cutaneous lupus (SCLE) [25]. While it has
lesions. This dermoscopic finding demonstrates perifollicular           been reported that the dotted vessel pattern in DLE is mostly



Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                     7
Table 5. Analysis of differences in dermoscopic findings according to lesion duration in patients with
                                    cutaneous lupus erythematosus.
                                                                         Lesion duration
                     Dermoscopic features                  12 ≤ months                 12 > months                     Pa
    Follicular features, N (%)
    Follicular keratotic plugs                                  9 (50)                   21 (70)                     0.166
    Absence of follicular openings                              1 (5.6)                    8 (26.7)                  0.125
    Reduced number of follicular openings                       0 (0)                      3 (10)                    0.282
    Fibrotic white dots                                         1 (5.6)                    7 (23.3)                  0.229
    Pinpoint white dots                                         1 (5.6)                    5 (16.7)                  0.388
    Follicular red dots                                         1 (5.6)                    4 (13.3)                  0.637
    Yellow dots                                                 2 (11.1)                   0 (0)                     0.136
    Black dots                                                  2 (11.1)                   2 (6.7)                   0.624
    Dilated follicles                                           1 (5.6)                    2 (6.7)                   1.000
    Perifollicular surface, N (%)
    Perifollicular white color                                  8 (44.4)                 11 (36.7)                   0.594
    Perifollicular scaling                                      3 (16.7)                 10 (33.3)                   0.317
    Perifollicular erythema                                     2 (11.1)                   1 (3.3)                   0.547
    Perifollicular pigmentation                                11 (42.3)                   2 (6.7)                   0.032
    Interfollicular features, N (%)
    White structureless areas                                  10 (55.6)                 22 (73.3)                   0.206
    Pink-white background                                      12 (66.7)                 17 (56.7)                   0.493
    Speckled brown pigmentation                                 4 (22.2)                  10 (33.3)                  0.412
    Honeycomb pigment pattern                                   1 (5.6)                    2 (6.7)                   1.000
    Peripheral pigmentation                                     4 (22.2)                   7 (23.3)                  1.000
    White scales                                               13 (72.2)                 17 (56.7)                   0.281
    Yellow (scales and crusts)                                  4 (22.2)                   6 (20)                    1.000
    White rosettes                                              3 (16.7)                   4 (13.3)                  1.000
    Shiny white lines                                           4 (22.2)                   5 (16.7)                  0.711
    Blue-gray dots/globules                                     0 (0.0)                    9 (30.0)                  0.018
    Erosions/ulcerations                                        3 (16.7)                   7 (23.3)                  0.722
    Vessel pattern, N (%)
    Thick Arborizing vessels                                    3 (16.7)                   6 (20)                    1.000
    Dotted vessels                                              3 (16.7)                 15 (50)                     0.021
    Hairpin vessels                                             5 (27.8)                   3 (10)                    0.132
    Linear vessels                                              7 (38.9)                 19 (63.3)                   0.100
    Polymorphous vessels                                        2 (11.1)                   0 (0)                     0.136
a
    Pearson Chi-Square, Fisher Exact test.


observed in scalp DLE [18], it was found more frequently in      dermoscopic findings were pink-red background and linear
non-scalp DLE in our study and a study by Ankad et al [34].      vessels, while follicular plugs were relatively less common [13].
When defining dermoscopic red dot structures, follicular         Similar dermoscopic findings were also observed in our
and non-follicular placement should be considered. In ad-        study. Due to the clinical course and good prognosis of LET,
dition, as dotted vessels can often be seen in inflammatory      it is important to differentiate it from classical DLE [36].
dermatoses, the clinician should look for specific clues for     Larger studies including the dermoscopic findings of LET are
diagnosis [35].                                                  warranted.
      Few studies have examined the dermoscopic findings                It was previously reported that the dermoscopic findings
of LET. Zychowska et al reported that the most common            of scalp DLE included “arborizing vessels overlying large




8                                                                       Original Article | Dermatol Pract Concept. 2024;14(1):e2024040
Figure 1. Dermoscopic presentation of follicular features. (A) Follicular plugs. (B) Absence of follicular openings. (C) Reduced number
of follicular openings. (D) Fibrotic white dots. (E) Follicular red dots. (F) Yellow dots. (G) Black dots. (H) Dilated follicles.




Figure 2. Dermoscopic features of interfollicular features-part I. (A) White structureless areas. (B) Pink-white background (black arrow) and
peripheral pigmentation (w​​​​​​​hite arrow). (C) Speckled brown pigmentation. (D) Honeycomb pigment pattern. (E) White scales. (F) Yellow
scales and crusts.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                             9
                  Figure 3. Dermoscopic features of interfollicular features-part II. (A) White rosettes. (B) Shiny white
                  lines. (C) Blue-gray dots/globules. (D) Erosions/ulcer​​​​​​​ations.




                  Figure 4. Dermoscopic features of perifollicular surface. (A) Perifollicular white color. (B) Perifollic-
                  ular scaling. (C) Perifollicular erythema. (D) Perifollicular pigmenta​​​​​​​tion.




yellow dots,” which was highly specific for inactive DLE le-                 The dermoscopic appearance of “white perifollicular
sions [28]. In our study, this finding was observed in a pa-            color” has rarely been reported in DLE patients with scalp
tient with LET. Histopathologically, LET is characterized by            location [29,39]. The clinical presentation of DLE with lip
minimal epidermal changes (epidermal atrophy, vacuolar de-              location can be confused with premalignant lesions such as
generation of basal cells, hyperkeratosis) and minimal follic-          actinic cheilitis and lip location of inflammatory skin dis-
ular plugging [37]. In this respect, it should not be forgotten         eases. Yellow scales and crust formations are among the der-
that follicular changes may be observed on dermoscopy.                  moscopic findings of DLE with lip location and are reported



10                                                                            Original Article | Dermatol Pract Concept. 2024;14(1):e2024040
Figure 5. Dermosc​​​​​​​opic findings in vessel pattern. (A) Thick arborizing vessels. (B) Dotted vessels. (C) Hairpin vessels. (D) linear vessels.
(E) Polymorphous vessels.




to be statistically more common than in the aforementioned                 to CLASI-A were not seen in patients with LET, these der-
diseases [25]. According to a 2018 study, telangiectatic ves-              moscopic features were attributed to DLE activity. Although
sels and scales were most common in lip DLE, but scales                    studies have recommended the use of CLASI in patients with
subtyping was not performed [1]. In another study, the most                LET, CLASI activity and damage scores have been found to
common vessel pattern in lip DLE was reported to be the                    be lower than in other CLE subtypes [42]. In this study, we
hairpin pattern (71.4%) [18]. Scales and hairpin vessels were              were unable to compare dermoscopic findings in patients with
also among the most common findings in our study.                          LET according to CLASI activity for reasons such as the small
    Although the dermoscopic appearance of “shiny white                    number of patients and the fact that the edema seen in LET
lines” is mostly seen in scalp DLE [32], it was also detected in           patients is not taken into account in the CLASI scoring system.
50.0% of patients with lip location in our study. Ayhan et al                   Fibrotic white dots, honeycomb pigment pattern, blue-
observed a 20.4% rate of yellowish-white streaks in dermo-                 gray dots/globules were detected more frequently in patients
scopic imaging of the labial mucosa in healthy people [40].                with a high CLASI-D score. Our data support previous
Therefore, comparing involved and uninvolved labial areas                  studies indicating that fibrotic white dots are a precursor of
in the same patients may enable a clearer evaluation of our                white structureless areas [18], and white structureless areas
study data.                                                                are associated with late DLE [19,32]. As DLE lesions expand
    It has been shown in the literature and in our study that              and grow, squamae and pigmentation begin to appear at the
follicular plugs are more common in patients with high                     periphery of the lesion [41].
­CLASI-A scores, in parallel with disease activity [1,19]. As                   In the literature, it was reported that “branching vessels”
DLE lesions expand and grow, squamae and pigmentation                      were more common in late scalp DLE lesions [1,43]. In the
begin to appear at the periphery of the lesion [41]. The pe-               present study, no such difference was observed according
ripheral hyperpigmentation associated with high CLASI-A                    to CLASI-D score. This may be because CLASI-D does not
score seen in our study may be an indicator that DLE lesions               evaluate vessel patterns.
are growing and have not progressed to the destructive phase.                   Patients with discoid LE present distinct pigmentation
    In our study, findings of polymorphous vessels were                    findings on dermoscopy such as honeycomb pigment pat-
more common in the dermoscopic images of patients with                     tern, speckled pigmentation, perifollicular pigmentation, pe-
high ­CLASI-A scores. It is known that erythema, one of the                ripheral pigmentation, and blue-gray dots/globules [34]. In
­CLASI-A components, is associated with the hyperemia that                 the literature, different results have been reported regarding
accompanies inflammation [10]. We believe that the more                    the relationship between pigmentation findings and DLE ac-
frequent observation of vessels may be related to this in-                 tivity. Gomez-Quispe et al. reported a higher incidence of
flammation. Since significant dermoscopic findings related                 incontinentia pigmenti (scattered brown discoloration and



Original Article | Dermatol Pract Concept. 2024;14(1):e2024040                                                                                 11
blue-gray dots) on dermoscopy of active scalp DLE [32].            findings. CLASI scoring severity in patients with LET was
Ankad et al stated that blue-gray dots/globules can be seen        not associated with dermoscopic findings.
in the inactive period [44], while another study emphasized
that blue-gray dots/globules can be seen in both active and
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