10.5826/dpc.1203a125
Introduction: Lichen sclerosus (LS), is an uncommon inflammatory dermatosis with preferential involvement of anogenital region. Diagnosis of LS is mainly clinical, but clinical differentiation from conditions like vitiligo, morphea may be a difficult task at times that often requires histological analysis. Dermoscopy is one such non-invasive tool which can help diagnose the disease. There is paucity of Indian data on dermoscopy of LS.
Objectives: To evaluate clinical, dermatoscopic patterns of LS and correlate them with histopathology.
Methods: The study was conducted in a tertiary hospital after obtaining consent from 20 patients. OITEZ e-scope digital microscope was used to evaluate the lesions. Both polarized and nonpolarized mode were used and skin biopsy was done to confirm diagnosis.
Results: Based on morphology, LS was classified as scleroatrophic lesions (61.5%), guttate lesions (30.8%) and hyperkeratotic lesions (7.7%). Dermoscopic analysis revealed structureless white to yellow areas  as most common finding (100%) followed by chrysalis like structure (80.8%). Linear irregular vessels were seen in 61.5% lesions and perifollicular scaling in 50.0% lesions. Keratotic plugs were seen in 50.0% lesions. A new characteristic finding, “rosettes” was seen in 38.5% lesions has never been reported with LS before. Non polarized mode was particularly useful for identifying texture changes, keratotic plugs and minute scales which were not visible otherwise.Conclusions: Dermoscopy is a simple diagnostic tool that helps in the early diagnosis of LS with specific pattern which can avoid invasive procedure like biopsy. Both non-polarised and polarized dermoscopy must be done to visualize the changes of LS well.
text/xml
2160-9381
1854
en
Jayati Shailesh Dave
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
chrysalis like structure, comedo like openings, dermoscopy, extragenital lichen sclerosus, keratotic plugs, rosettes, white structureless areas.
Dermoscopic evaluation of extragenital lichen sclerosus et atrophicus
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-06-28
2022-07-28
2022-09-13
e2022125
Dermatol Pract Concept
Introduction: Lichen sclerosus (LS), is an uncommon inflammatory dermatosis with preferential involvement of anogenital region. Diagnosis of LS is mainly clinical, but clinical differentiation from conditions like vitiligo, morphea may be a difficult task at times that often requires histological analysis. Dermoscopy is one such non-invasive tool which can help diagnose the disease. There is paucity of Indian data on dermoscopy of LS.
Objectives: To evaluate clinical, dermatoscopic patterns of LS and correlate them with histopathology.
Methods: The study was conducted in a tertiary hospital after obtaining consent from 20 patients. OITEZ e-scope digital microscope was used to evaluate the lesions. Both polarized and nonpolarized mode were used and skin biopsy was done to confirm diagnosis.
Results: Based on morphology, LS was classified as scleroatrophic lesions (61.5%), guttate lesions (30.8%) and hyperkeratotic lesions (7.7%). Dermoscopic analysis revealed structureless white to yellow areas  as most common finding (100%) followed by chrysalis like structure (80.8%). Linear irregular vessels were seen in 61.5% lesions and perifollicular scaling in 50.0% lesions. Keratotic plugs were seen in 50.0% lesions. A new characteristic finding, “rosettes” was seen in 38.5% lesions has never been reported with LS before. Non polarized mode was particularly useful for identifying texture changes, keratotic plugs and minute scales which were not visible otherwise.Conclusions: Dermoscopy is a simple diagnostic tool that helps in the early diagnosis of LS with specific pattern which can avoid invasive procedure like biopsy. Both non-polarised and polarized dermoscopy must be done to visualize the changes of LS well.
Jayati Shailesh Dave
2022/07/28
10.5826/dpc.1203a125
e2022125
Department of Dermatology, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai
2160-9381
chrysalis like structure, comedo like openings, dermoscopy, extragenital lichen sclerosus, keratotic plugs, rosettes, white structureless areas.
en
e2022125
Dermoscopic evaluation of extragenital lichen sclerosus et atrophicus
https://dpcj.org/index.php/dpc/article/download/1854/1649
                    Dermatology Practical & Conceptual


       Dermoscopic Evaluation of Extragenital Lichen
                 Sclerosus et Atrophicus
                                   Sunanda Arun Mahajan1, Jayati Shailesh Dave1


1 Department of Dermatology, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai



Key words: chrysalis like structure, dermoscopy, extragenital lichen sclerosus et atrophicus, rosettes, white structureless areas
Citation: Mahajan SA, Dave JS. Dermoscopic evaluation of extragenital lichen sclerosus et atrophicus.
Dermatol Pract Concept. 2022;12(3):e2022125. DOI: https://doi.org/10.5826/dpc.1203a125
Accepted: October 31, 2021; Published: July 2022
Copyright: ©2022 Mahajan 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: Jayati Shailesh Dave, MD, Department of Dermatology, OPD 117, Seth G.S. Medical College and K.E.M Hospital,
Parel, Mumbai, 400012 Telephone number: 9987054564. E-mail address: jayatidave20@gmail.com




  ABSTRACT              Introduction: Lichen sclerosus (LS), is an uncommon inflammatory dermatosis with preferential in-
                        volvement of anogenital region. Diagnosis of LS is mainly clinical, but clinical differentiation from
                        ­conditions like vitiligo, morphea may be a difficult task at times that often requires histological
                         ­analysis. Dermoscopy is one such non-invasive tool which can help diagnose the disease. There is
                          paucity of Indian data on dermoscopy of LS.
                        Objectives: To evaluate clinical, dermatoscopic patterns of LS and correlate them with histopathology.
                        Methods: The study was conducted in a tertiary hospital after obtaining consent from 20 patients.
                        OITEZ e-scope digital microscope was used to evaluate the lesions. Both polarized and nonpolarized
                        mode were used and skin biopsy was done to confirm diagnosis.
                        Results: Based on morphology, LS was classified as scleroatrophic lesions (61.5%), guttate lesions
                        (30.8%) and hyperkeratotic lesions (7.7%). Dermoscopic analysis revealed structureless white to
                        ­yellow areas as most common finding (100%) followed by chrysalis like structure (80.8%). Linear
                         irregular vessels were seen in 61.5% lesions and perifollicular scaling in 50.0% lesions. Keratotic
                         plugs were seen in 50.0% lesions. A new characteristic finding, “rosettes” was seen in 38.5% lesions
                         has never been reported with LS before. Non polarized mode was particularly useful for identifying
                         texture changes, keratotic plugs and minute scales which were not visible otherwise.
                        Conclusions: Dermoscopy is a simple diagnostic tool that helps in the early diagnosis of LS with
                        specific pattern which can avoid invasive procedure like biopsy. Both non-polarised and polarized
                        dermoscopy must be done to visualize the changes of LS well.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022125                                                                      1
Introduction                                                       Inclusion criteria
                                                                   Untreated patients of extragenital LS willing to give consent
Lichen sclerosus (LS), is an uncommon inflammatory der-            with histopathology suggestive of the disease were included
matosis with preferential involvement of anogenital region.        in the study.
Isolated extragenital LS is seen in 6% of cases, and associ-
ation with genital LS seen in 15-20% cases [1]. Women are          Exclusion criteria
affected more commonly than men [2]. Extragenital LS -             Patients already on treatment for the disease, or not willing
found to be relatively common on the neck and shoulder - is        for biopsy were excluded from the disease.
generally asymptomatic, but can occasionally be pruritic
[2]. Extragenital LS presents as white polygonal porcelain         Statistical analysis
atrophic papules that coalesce to form plaque studded with         Statistical analysis was performed using descriptive tools
comedo-like plugs or evenly spaced dells which corresponds         such as percentage and frequency. Results were statistically
to appendageal ostia [2].                                          described as types of dermoscopic patterns.
    Diagnosis of LS is mainly clinical, and sometimes clinical
differentiation from other hypopigmentary conditions such
as vitiligo and scleroatrophic disorder like morphea may
                                                                   Results
be a difficult task that often requires histological analysis.     There were 20 patients (12 females, 8 males) and 26 lesions
Dermoscopy is one such non-invasive tool which can help            included in the study. The patients with extragenital LS
develop a pattern to diagnose the disease.                         with mean duration of disease of 20.4 months (minimum 2
                                                                   months and maximum 6 years) and mean age of 37.8 years
Objectives                                                         (youngest 12 years and oldest 71 years) presented with hy-
                                                                   popigmented lesions at different sites. The lesions were as-
To study dermoscopic patterns of extragenital LS in series of      ymptomatic in 15 patients and pruritic in 5 patients. On
patients with brown skin and correlate these patterns with         examination the maximum number of lesions were seen
histopathology.                                                    on the trunk (101, 38.5%) followed by lower extremities
                                                                   (6, 23.1%), upper extremities (9, 34.2%) and the least on
Methods                                                            face (1, 3.8%). Koebner phenomenon was seen in 4 patients.
                                                                   Patients presented with classical ivory colored small polyg-
Patients                                                           onal papules coalescing to form plaques or hypopigmented
This was an observational case series study conducted in the       atrophic plaques. Four patients also had multiple guttate
Department of Dermatology of a tertiary hospital, from July        macules of LS. LS of the genitalia was seen in 3 patients and
2018 to January 2020. A total of 20 patients with clinical fea-    2 patients had biopsy-proven morphea in addition. Lesions
tures of LS were enrolled in the study. A complete history and     were classified into 3 groups based on morphology namely
dermatological examination were performed after obtaining          scleroatrophic plaque (16) (Figure 1A)], guttate (8) (Figure 1B)
written informed consent from the patient. Demographic             and hyperkeratotic having predominantly keratotic plugs
data, such as age, gender, and clinical variables in terms of      with underlying sclerosis (2) (Figure 1C).
site of lesions and disease duration were documented. Lesions         All lesions (Table 1) of extragenital LS revealed patchy
with less than 2 years and more than 2 years duration were         structureless white to yellow areas (WSA) (Figure 2A) which
arbitrarily termed as early and late lesions. A first biopsy was   were most commonly associated with irregularly arranged
taken from clinically active lesion and a second biopsy was        linear vessels (16, 61.5%), linear branching vessels (10,
taken if patient had genital LS or different morphology of LS.     38.5%) or dotted vessels (4, 15.4%) and glomerular ves-
                                                                   sels (4, 15.4%). The linear vessels were of varying calibers,
Dermoscopic examination                                            whereas dotted vessels were arranged in a random fashion.
OITEZ e-scope digital microscope [DP-M17 filter e-scope            Erythematous areas were seen in 10 (38.5%) lesions which
pro (optical 200x)] with 20x and 200x magnification was            were accompanied by vessels. Chrysalis like structure which
used for dermoscopy and an alcohol-based sanitizer was             is shiny white streaks was seen in 21 (80.8%) patients
used as immersion fluid. Both polarized and non-polarized          (Figure 2B). Comedone-like opening (CLO) defined as ovoid
modes were employed in the study. The dermoscopic images           or round craters filled with brownish-black material were
were saved and the findings noted on an excel sheet after          seen in 9 (34.6%) lesions whereas keratotic plugs defined
evaluation by two individual independent authors. Param-           as invaginations filled by yellowish material were seen in
eters such as vessels, scales, follicular findings, background     13 (50.0%) sites (Figure 3, A and B). Peppering blue grey
color, morphology and specific findings if any were noted.         dots was seen in 9 (34.6%) lesions (Figure 3, C and D).



2                                                                      Original Article | Dermatol Pract Concept. 2022;12(3):e2022125
 Figure 1. (A) Two shiny porcelain white colored atrophic plaques on axilla typical of scleroatrophic plaque of Lichen sclerosus (LS).
 (B) Multiple discrete hypopigmented rain drop like slightly atrophic macules typical of guttat’ lesions of LS.(C) Multiple hypopig-
 mented sclerotic guttate lesions coalescing to form plaques studded with multiple Comedone-like openings typical of hyperkeratotic LS.


                  Table 1. Morphology and duration wise distribution of dermoscopic findings
                                   Scleroatrophic                                                       Duration           Duration
   Dermoscopic          Total         plaques             Guttate            Hyperkeratotic             ≤ 2 years          >2 years
 findings, N (%)         (N)          (N = 16)            (N = 8)            plaques (N = 2)            (N = 20)            (N = 6)
 White structure-        26          16 (100%)            8 (100%)              2 (100%)               20 (100%)          06 (100%)
 less areas
 Chrysalis               21          13 (81.3%)          6 (75.0%)              2 (100%)               16 (80.0%)         05 (83.3%)
 structures
 Linear irregular        16          10 (62.5%)          5 (62.5%)              1 (50.0%)              13 (65.0%)         3 (50.0%)
 vessels
 Perifollicular          13           8 (50.0%)          4 (50.0%)              1(50.0%)                9 (45.0%)         4 (66.7%)
 scales
 Keratotic plug          13           6 (37.5%)           5 (62.5%)              2 (100%)              10 (50.0%)         3 (50.0%)
 Erythematous            10           6 (37.5%)          2 (25.0%)             01 (50.0%)               9 (45.0%)         1 (16.6%)
 areas
 Rosettes                10           5 (31.3%)          5 (62.5%)              1 (50.0%)               8 (40.0%)         2 (33.3%)
 Comedo-like              9           5 (31.3%)          2 (25.0%)               2 (100%)               6 (30.0%)         3 (50.0%)
 openings
 Peppering of             9           5 (31.3%)          4 (50.0%)                   0                  06 (30%)          3 (50.0%)
 pigment


Peri-follicular scales were observed in 13 (50.0%) lesions,            erosions were absent in our patients. Hemorrhagic spots
generalized white colored scales in 12 (46.2%) lesions and             were seen in a single patient.
collarette like in 2 (7.7%) lesions (Figure 4). Pigment net-               We found that non-polarizer mode was particularly useful
work was seen in 1 (3.8%) patient. Fibrotic beams and                  for identifying texture change (due to sclerosis), CLO and minute



Original Article | Dermatol Pract Concept. 2022;12(3):e2022125                                                                            3
Figure 2. (A) Dermoscopy of scleroatrophic lesion with OITEZ e-scope digital microscope (20x magnification) suggestive of white to yellow
structureless areas (yellow arrow) studded with multiple keratotic yellow –white plugs (blue star), chrysalis like structure (green triangle) and
linear irregular vessels (red arrow). (B) Chrysalis structures (red arrow) seen on polarizer mode (20x) characterized by bright white orthogo-
nal linear streaks seen only on polarized dermoscopy is suggestive of underlying dermal collagen homogenization.




Figure 3. (A) Comedone-like openings (red arrow) and yellowish-white keratotic follicular plugs (yellow arrow) seen on polarizer mode
(20x). (B) Better appreciated on non-polarizer mode. (C,D) Peppering blue-gray dots suggestive of melanin incontinence seen on polarizer
mode (100x).



scales which were not visible otherwise (Figure 3, B and D).              arranged as a 4 leaf clover were seen in 10 (38.4%) lesions
In addition, we observed stretched eccrine openings and ro-               (Figure 5). In few patients with multiple CLO, we noticed that
settes on polarized mode. Rosettes defined as 4 white points,             there was central clustering with radial arrangement (Figure 6).



4                                                                              Original Article | Dermatol Pract Concept. 2022;12(3):e2022125
Figure 4. (A) Collarete scaling. (B) Peri-follicular scales. (C) generalized scaling appreciated on 20x polarizer mode. (D) Non polarized mode
was particularly useful to identify minute scales not visible to naked eyes.




Figure 5. Rosette formation is also called as four-dot clods, seen on polarized dermoscopy (200x) as white shiny structures resembling a 4
leaf clover (red circle).

    Histopathological examination findings of 21 biopsied                vessel morphology and distribution , follicular involvement,
lesions are enlisted in Table 2 (Figure 7).                              surface changes such as scales and disease specific additional
                                                                         clues. Dermoscopy hallmarks of LS on polarizing mode in-

Conclusions                                                              clude WSA with linear and dotted vessels suggestive of active
                                                                         lesion [3]. Keratotic plugs suggestive of follicular plugging
Dermoscopy-aided algorithm of inflammatory disorders are                 [3]. Chrysalis like structures are seen as shiny, bright white
defined by their characteristics based on background color,              orthogonal linear streaks which are also commonly observed



Original Article | Dermatol Pract Concept. 2022;12(3):e2022125                                                                              5
Figure 6. (A,B) central clustering with radial arrangement of comedone-like openings (CLO) and keratotic plugs. (C) Stretched eccrine open-
ings suggestive of stretched acrosyringia due to upper dermal sclerosis and atrophic epidermis seen on polarizer mode (200x). (D) Grouping
of CLO in coalescing atrophic papules of LS described as corymbiform pattern seen on non-polarizer mode (200x).




     Table 2. Histopathology findings (N = 21)                         in dermatofibroma, Spitz nevus, melanoma and basal cell
    Histopathology findings, N (%)                                     carcinoma [4].
 Hyperkeratosis                                 21 (100%)                  Dermoscopic features of LS correlate with histopatho-
 Collagen homogenization                        17 (80.9%)             logical findings such as WSA and correspond to epidermal
 Perivascular infiltrate                        13 (61.9%)             atrophy and dense diffuse hyalinization of superficial dermis
 Epidermal atrophy                              13 (61.9%)             [5]. CLO is suggestive of dells which correspond to appenda-
 Dilated lymphatics                             12 (57.1%)             geal ostia [5,6]. Chrysalis structures are due to increased col-

 Vacuolar interface                             10 (47.6%)             lagen deposition [4]. Scaling seen in LS lesions corresponds
                                                                       to hyperkeratosis while the peppering blue gray dots cor-
 Follicular plugs                               10 (47.6%)
                                                                       respond to melanin incontinence seen after vacuolar inter-
 Melanophages                                    9 (42.9%)
                                                                       face dermatitis. Telangiectasia and dotted vessels represent
 Band like infiltrate                            7 (33.3%)
                                                                       the easy visibility of vessels due to inflammation from an
 Papillary dermal edema                          6 (28.6%)
                                                                       atrophic epidermis [5]. Rosettes are a form of white shiny
 Dilated blood vessels                           4 (19.0%)
                                                                       structures or are white shiny lines and white shiny areas.
 Perifollicular infiltrate                       3 (14.3%)             White shiny areas and lines have been correlated to dermal




6                                                                           Original Article | Dermatol Pract Concept. 2022;12(3):e2022125
fibrosis whereas exact correlation of rosette is unknown. It            in 80.8% study participants which was comparable to study
has been suggested that interaction of the polarized light              by Liu et al (84%) and lower in study by Errichetti et al
with narrowed or keratin-filled adnexal openings could be               (40%) and Borges et al (26.7%) [6,9,10] (Table 3).
the morphological correlation toward formation of rosettes.                 Scaling particularly peri-follicular (50.0%) represented a
Rosettes have been linked histologically with alternating               very common feature of LS in our study which was less as com-
focal hyperkeratosis and normal corneal layer and kera-                 pared to previous study [6]. Early lesions of LS show keratotic
tin-filled openings. Haspeslagh et al proved on transverse              plugs on dermoscopy whereas older ones demonstrate chrysalis
sections that smaller rosettes are mainly caused by polariz-            like structure [10]. However, in our study there was not much
ing horny material at infundibular level in adnexal openings            difference in these 2 parameters, instead we saw that vascular
and larger rosettes mainly by concentric perifollicular fibro-          findings like irregular linear vessels, and erythematous areas
sis. We believe that rosette in case of LS will be due to same          were more frequent in early lesions. Peppering blue-gray dots
reasons [7]. Dermoscopy of LS on non polarizing mode is a               suggestive of melanin incontinence was seen more frequently in
useful adjunct to observe scaling, tiny CLO and keratotic               old lesions of LS probably indicating lesion inactivity (Table1).
plugs which aid in diagnosis. The closest mimicker of LS                    Rosettes are a particular finding we want to highlight
clinically and histopathologically is morphea, which can be             that has not been described before with LS. Stretched ec-
differentiated by dermoscopy. Shim et al found a statistically          crine openings represent stretched acrosyringia of the eccrine
significance for WSA and CLO in LS whereas fibrotic beams               glands due to sclerosis of the upper dermis and atrophy of
crossed by spreading telangiectasia for morphea [8].                    the epidermis. The grouping of CLO in coalescing atrophic
    WSA were seen in all patient of our study similar to Liu et         papules of LS better visualized on dermoscopy has been de-
al and Borges et al whereas it was seen in 88.6% patients in            scribed as cribriform or corymbiform [2].
a study by Errichetti et al [6,9,10]. Shim et al reported much              On dermoscopy keratotic plugging was seen in more
lesser percentage (66.7%) of WSA [8]. CLO was seen in                   number compared to follicular plugging on histopathology.
34.6% of patients which was lesser than Shim et al (77.8%)              This could be because the keratin filled craters correspond
[8]. The most common vessel morphology observed in our                  to adnexal (eccrine and follicular openings ) which may not
study was linear irregular vessels (61.53%) which was less              always be visualized in a particular section of skin biopsy.
compared to Liu et al (72.8%) and higher than Errichetti                Broader band of hyalinization was associated with promi-
et al (25.7%) [6,9]. Dotted vessels were observed in 15.4%              nent chrysalis like structures.
patients which was similar to Liu et al (16.8%), Borges et al               Limitations of our study were the small sample size, the
(13.3%), lesser as compared to Errichetti et al (28.6%) and             fact we couldn’t study multiple lesions on the same patient
higher as compared to Shim et al (5.6%) [6,8,9,10]. Chrys-              and do their biopsies to correlate their results with dermo-
alis-like structure suggestive of collagen deposition was seen          scopic findings.




Figure 7. Histopathology examination of Lichen sclerosus (H&E, 20x magnification) shows hyperkeratosis (red arrow), follicular plugging
(yellow star), atrophy of epidermis with flattening of rete ridges (green arrow), focal basal cell degeneration (blue triangle), subepidermal
band of homogenization (black arrow) corresponding to the sclerosis with a lichenoid infiltrate of lymphocytes beneath it (white arrow) and
dilated lymphatics (orange arrow).




Original Article | Dermatol Pract Concept. 2022;12(3):e2022125                                                                             7
       Table 3. Dermoscopic profile of Lichen sclerosus and comparison with other published data
    Dermoscopic features, N (%)        Present study Errichetti et al [6] Shim et al [8] Liu et al [9] Borges et al [10]
 White structureless areas                 26(100)             31 (88.6)              12(66.7)         124(99.2)             15(100)
 Chrysalis like structure                  21(80.8)            14 (40.0)                  --           105(84.0)             4(26.7)
 Linear irregular vessels                  16(61.5)             9 (25.7)                  --            91(72.8)                 --
 Yellowish-white keratotic                 13(50.0)             28(80.0)                  --            63(50.4)             5(33.3)
 follicular plugs
 Scales (perifollicular)                   13(50.0)            15 (42.9)                  --                --          9 (60.0%)(type
                                                                                                                         not specified)
 Linear branching vessels                  10(38.5)              1(2.9)               9(50.0)               --               5(33.3)
 Comedone-like openings                     9(34.6)              1(2.9)               14(77.8)              --                   --
 Dotted vessels                             4(15.4)             10(28.6)               1(5.6)           21(16.8)             2 (13.3)



     In conclusion, LS is a rare disorder that can be difficult          2009;145(5):618. DOI: 10.1001/archdermatol.2009.28. PMID:
to differentiate clinically from a number of disorders of hy-            19451524.
                                                                      5. Ankad B, Beergouder S. Dermoscopic patterns in lichen
popigmentation and sclero-atrophic disorders, and hence re-
                                                                         sclerosus: A report of three cases. Indian Dermatol Online
quires skin biopsy. Dermoscopy is a simple diagnostic tool
                                                                         J. 2015;6(3):237-240. DOI: 10.4103/2229-5178.156450. PMID:
that helps in the early diagnosis of LS with specific and char-          26009734. PMCID: PMC4439768.
acteristic patterns which can avoid invasive procedure like           6. Errichetti E, Lallas A, Apalla Z, Di Stefani A, Stinco G. Der-
biopsy. Both non-polarized and polarized dermoscopy must                   moscopy of Morphea and Cutaneous Lichen Sclerosus: Clini-
be done to visualize the changes of LS well. Larger sample size            copathological Correlation Study and Comparative Analysis.
                                                                           Dermatology. 2018;233(6):462–470. DOI: 10.1159/000484947.
study is required to ascertain the newer dermoscopic findings.
                                                                           PMID: 29237158.
                                                                      7.   Haspeslagh M, Noë M, De Wispelaere I, et al. Rosettes and other
References                                                                 white shiny structures in polarized dermoscopy: Histological cor-
                                                                           relate and optical explanation. J Eur Acad Dermatol Venereo.l
 1. Nóbrega MM, Cabral F, Corrêa MC, Barcaui CB, Bressan                   2016;30:311-313. DOI: 10.1111/jdv.13080. PMID: 25786770.
    AL, Gripp AC. Lichen sclerosus associated with localized          8.   Shim WH, Jwa SW, Song M, et al. Diagnostic usefulness of
    scleroderma: Dermoscopy contribution. An Bras Dermatol.                dermatoscopy in differentiating lichen sclerous et atrophicus
    2016;91(4):534–536. DOI: 10.1590/abd1806-4841.20164813.                from morphea. J Am Acad Dermatol. 2012;66(4):690–691.
    PMID: 27579757. PMCID: PMC4999120.                                     DOI: 10.1016/j.jaad.2011.06.042. PMID: 22421117.
 2. Meffert JJ, Davis BM, Grimwood RE. Lichen sclerosus. J Am         9.   Liu J, Hao J, Liu Y, Lallas A. Dermoscopic features of lichen scle-
    Acad Dermatol. 1995;32(3):393–416. DOI: 10.1016/0190-                  rosus in Asian patients: a prospective study. J Eur Acad Derma-
    9622(95)90060-8. PMID: 7868709.                                        tol Venereol. 2020;34(11):e720-e721. DOI: 10.1111/jdv.16540.
 3. Al-Refu K. Dermoscopy is a new diagnostic tool in diagno-              Epub 2020 Jun 8. PMID: 32343433.
    sis of common hypopigmented macular disease: a descriptive       10.   Larre Borges A, Tiodorovic-Zivkovic D, Lallas A, et al.
    study. Dermatology Reports. 2018;11(1):7916. DOI: 10.4081/             Clinical, dermoscopic and histopathologic features of gen-
    dr.2018.7916. PMID: 31119026. PMCID: PMC6509478.                       ital and extragenital lichen sclerosus. J Eur Acad Der-
 4. Marghoob AA, Cowell L, Kopf AW, Scope A. Observation of                matology       Venereol.       2013;27(11):1433–1439.        DOI:
    chrysalis structures with polarized dermoscopy. Arch Dermatol.         10.1111/j.1468-3083.2012.04595.x. PMID: 22646723.




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