10.5826/dpc.1201a30
Introduction: Facial melanosis is one of the most common reasons for which patients refer to a dermatologist in Nepal.
Objectives: The objective of this study was to evaluate the dermoscopic findings of common facial melanoses and correlate them with findings from Wood lamp examination.
Methods: This was a cross-sectional study conducted at the Department of Dermatology and Venereology, Nepal Medical College and Teaching Hospital. We recruited a total of 204 patients from July 2020 to March 2021. The most common diagnosis was melasma (37 patients) followed by melasma with steroid-induced rosacea-like dermatitis (29 patients).  After collecting clinical and demographic data, patients underwent Wood lamp and dermoscopic examination.
Results: Dermoscopy of ashy dermatosis and nevus of Ota revealed blue-gray pigmentation forming a curvilinear pattern; café-au-lait macule and nevus spilus revealed a light brown reticular pattern with follicular sparing; and a reticular and hem-like pattern of pigmentation was observed in clofazimine-induced pigmentation, peribuccal pigmentation of Brocq and periorbital pigmentation. The degree of agreement between Wood lamp and dermoscopic findings was found to be statistically significant in melasma (κ = 0.701, P = 0.0001) and melasma with steroid-induced rosacea-like dermatitis (κ = 0.628, P = 0.0001). While the agreement between the two techniques was 100% for epidermal types, it decreased to 44.8% for dermal melasma and 61.5% for dermal melasma with steroid-induced rosacea-like dermatitis.
Conclusions: Dermoscopy is useful in assessing facial melanoses. It may be supplemented with Wood lamp examination to increase diagnostic accuracy.
text/xml
2160-9381
1757
en
Bibush Amatya
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Wood lamp
Evaluation of Dermoscopic Features in Facial Melanosis with Wood Lamp Examination
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-04-18
2022-02-02
2022-02-09
e2022030
Dermatol Pract Concept
Introduction: Facial melanosis is one of the most common reasons for which patients refer to a dermatologist in Nepal.
Objectives: The objective of this study was to evaluate the dermoscopic findings of common facial melanoses and correlate them with findings from Wood lamp examination.
Methods: This was a cross-sectional study conducted at the Department of Dermatology and Venereology, Nepal Medical College and Teaching Hospital. We recruited a total of 204 patients from July 2020 to March 2021. The most common diagnosis was melasma (37 patients) followed by melasma with steroid-induced rosacea-like dermatitis (29 patients).  After collecting clinical and demographic data, patients underwent Wood lamp and dermoscopic examination.
Results: Dermoscopy of ashy dermatosis and nevus of Ota revealed blue-gray pigmentation forming a curvilinear pattern; café-au-lait macule and nevus spilus revealed a light brown reticular pattern with follicular sparing; and a reticular and hem-like pattern of pigmentation was observed in clofazimine-induced pigmentation, peribuccal pigmentation of Brocq and periorbital pigmentation. The degree of agreement between Wood lamp and dermoscopic findings was found to be statistically significant in melasma (κ = 0.701, P = 0.0001) and melasma with steroid-induced rosacea-like dermatitis (κ = 0.628, P = 0.0001). While the agreement between the two techniques was 100% for epidermal types, it decreased to 44.8% for dermal melasma and 61.5% for dermal melasma with steroid-induced rosacea-like dermatitis.
Conclusions: Dermoscopy is useful in assessing facial melanoses. It may be supplemented with Wood lamp examination to increase diagnostic accuracy.
Bibush Amatya
2022/02/02
10.5826/dpc.1201a30
e2022030
Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
2160-9381
Wood lamp
en
e2022030
Jage M, Mahajan S. Clinical and dermoscopic evaluation of periorbital hyperpigmentation. Indian J Dermatopathol Diagn Dermatol. 2018;5(1):42-47. DOI: 10.4103/ijdpdd.ijdpdd_2_18.
Evaluation of Dermoscopic Features in Facial Melanosis with Wood Lamp Examination
https://dpcj.org/index.php/dpc/article/download/1757/1462
                    Dermatology Practical & Conceptual


         Evaluation of Dermoscopic Features in Facial
           Melanosis with Wood Lamp Examination
                                                          Bibush Amatya1


1 Nepal Medical College and Teaching Hospital, Kathmandu, Nepal



Key words: facial melanosis, melasma, Wood lamp, dermoscopy
Citation: Amatya B. Evaluation of dermoscopic features in facial melanosis with Wood lamp examination.
Dermatol Pract Concept. 2022;12(1):e2022030. DOI: https://doi.org/10.5826/dpc.1201a30
Accepted: July 25, 2021; Published: January 2022
Copyright: ©2022 Amatya. 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: This study was supported by the International Dermoscopy Society Research Seed Grant, 2019.
Competing interests: None.
Authorship: The author takes responsibility for this publication.
Corresponding author: Bibush Amatya, MBBS, MPH, MD Dermatology, Venereology and Leprology, Nepal Medical College and Teaching
Hospital, Kathmandu, Nepal. Email: bibush.amatya@nmcth.edu




  ABSTRACT             Introduction: Facial melanosis is one of the most common reasons for which patients refer to a der-
                       matologist in Nepal.
                       Objectives: The objective of this study was to evaluate the dermoscopic findings of common facial
                       melanoses and correlate them with findings from Wood lamp examination.
                       Methods: This was a cross-sectional study conducted at the Department of Dermatology and Vene-
                       reology, Nepal Medical College and Teaching Hospital. We recruited a total of 204 patients from July
                       2020 to March 2021. The most common diagnosis was melasma (37 patients) followed by melasma
                       with steroid-induced rosacea-like dermatitis (29 patients). After collecting clinical and demographic
                       data, patients underwent Wood lamp and dermoscopic examination.
                       Results: Dermoscopy of ashy dermatosis and nevus of Ota revealed blue-gray pigmentation forming
                       a curvilinear pattern; café-au-lait macule and nevus spilus revealed a light brown reticular pattern
                       with follicular sparing; and a reticular and hem-like pattern of pigmentation was observed in clo-
                       fazimine-induced pigmentation, peribuccal pigmentation of Brocq and periorbital pigmentation. The
                       degree of agreement between Wood lamp and dermoscopic findings was found to be statistically sig-
                       nificant in melasma (κ = 0.701, P = 0.0001) and melasma with steroid-induced rosacea-like dermatitis
                       (κ = 0.628, P = 0.0001). While the agreement between the two techniques was 100% for epidermal
                       types, it decreased to 44.8% for dermal melasma and 61.5% for dermal melasma with steroid-induced
                       rosacea-like dermatitis.
                       Conclusions: Dermoscopy is useful in assessing facial melanoses. It may be supplemented with Wood
                       lamp examination to increase diagnostic accuracy.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                 1
Introduction                                                          The data were uploaded onto a secure password-pro-
                                                                  tected database using Microsoft Excel. Data analysis was per-
Facial melanoses are characterized by abnormal pigmenta-          formed with the Statistical Package for Social Sciences (SPSS)
tion of the face. These disorders include, but are not limited    version 16 (SPSS Inc). Descriptive statistics were utilized to
to, ashy dermatosis, discoid lupus erythematosus, ephelides,      compute the mean and standard deviation (SD) of age and
melasma, melasma with steroid-induced rosacea-like derma-         frequency of facial melanoses. Wood lamp and dermoscopic
titis, peribuccal pigmentation of Brocq, periorbital hyper-       findings were analyzed using Cohen’s kappa coefficient, and
pigmentation, postinflammatory hyperpigmentation, and             correlation was established. A P value < 0.05 was considered
solar lentigo. Also included are various types of nevi, such      statistically significant.
as Becker nevus, blue nevus, compound nevus, Hori nevus,
intradermal nevus, junctional nevus, nevus of Ota, nevus
spilus, and verrucous epidermal nevus [1]. Facial melanoses
                                                                  Results
may also present as a result of ingestion of certain drugs like   A total of 204 patients provided informed consent to par-
amiodarone, antimalarials, antipsychotics, chloramphenicol,       ticipate in the study. Most participants were female (146,
clofazimine, pirfenidone and tetracycline [2].                    71.6%). The mean (SD) age of the participants was 34.04 ±
    The diagnosis and differentiation of these conditions are     13.17 years with a range 13-86 years. The highest percentage
based on history and clinical examination supplemented in         of participants (72.5%) belonged to the age group 21-40
some cases by Wood lamp and histopathological evaluation          years. In our sample, 24% had Fitzpatrick skin type III,
[3]. Dermoscopy is a noninvasive, in vivo technique that          65.7% had skin type IV, and 10.3% had skin type V.
allows visualization of the subsurface structures of skin             The most common diagnosis was melasma (47 patients,
that are normally not visible to the naked eye. Wood lamp         23%) followed by melasma with steroid-induced rosacea-like
examination is another non-invasive technique that helps          dermatitis (29 patients, 14.2%). The rarest observed con-
in the diagnosis of pigmentary disorders. It uses a specific      ditions were ashy dermatosis (1 patient), lentigo simplex
wavelength light source to distinguish depth of pigmentation      (1 patient), nevus of Ota (1 patient), and nevus spilus (1
depending on different degrees of auto-fluorescence [4]. There    patient). Female predominance was observed in melasma
are very few studies that have evaluated dermoscopic and          (4.2:1), melasma with steroid-induced rosacea-like dermatitis
Wood lamp findings for the diagnosis and classification of        (13.5:1), and ephelides (100:0). The two patients with nevus
all facial melanoses [5]; some studies have only focused on       of Ota and nevus spilus were males (Table 1).
melasma [6-8]. We therefore aimed to evaluate the dermo-              Wood lamp examination was performed in all patients.
scopic findings of common facial melanoses and correlate          Accentuation of pigmentation was observed in all cases of
them with findings from Wood lamp examination.                    acne-induced postinflammatory hyperpigmentation, blue
                                                                  nevus, café-au-lait macule, compound nevus, dermatosis
Methods                                                           papulosa nigra, discoid lupus erythematosus, ephelides, Hori
                                                                  nevus, junctional nevus, lentigo simplex, nevus of Ota, nevus
This was a cross-sectional study conducted at the Department      spilus, postinflammatory hyperpigmentation, seborrhoeic
of Dermatology and Venereology, Nepal Medical College and         keratosis, solar lentigo and verrucous epidermal nevus. Such
Teaching Hospital (NMCTH), Kathmandu, Nepal. The study            accentuation was not observed in patients with ashy derma-
subjects included all patients with a facial melanosis who        tosis and peribuccal pigmentation of Brocq. Epidermal as well
visited the dermatology outpatient department from July 1,        as dermal pigmentation were observed in melasma, melasma
2020, to March 31, 2021. All participants provided written        with steroid-induced rosacea-like dermatitis, dermal nevus,
informed consent for participation. The Institutional Review      periorbital hyperpigmentation and clofazimine induced
Committee of NMCTH granted approval to conduct the                pigmentation.
study (reference number 040–076/076).                                 The dermoscopic findings of common facial melanoses
    At the time of enrolment, the investigator filled a form      are given in Table 2. Acne-induced postinflammatory hyper-
to obtain information on patient age, sex, diagnosis, and         pigmentation was characterized by reddish brown homoge-
Fitzpatrick skin type. The diagnosis was based on clinical        nous pigmentation on a reddish background (Figure 1A), and
examination performed by a dermatologist. Clinical photo-         postinflammatory hyperpigmentation secondary to trauma
graphs were obtained using iPhone 6s plus (Apple® Inc). A         revealed a dark brown reticular or homogenous pattern with
dermatologist examined the participants with a Wood lamp          dark brown dots (Figure 1B). Dermoscopy of ashy dermatosis
(Derma India) to assess the depth of pigmentation, and the        and nevus of Ota revealed blue-gray pigmentation forming a
investigator performed dermoscopic examination (DermLite          curvilinear pattern (Figure 2). Dark brown reticular pattern
DL4, 3GenInc).                                                    with follicular sparing was observed in both café-au-lait macule



2                                                                    Original Article | Dermatol Pract Concept. 2022;12(1):e2022030
                          Table 1. Pattern and Gender Distribution of Facial Melanoses
                             Diagnosis                                 Males, n (%)          Females, n (%)   Number, n (%)
 Melasma                                                                  9 (19.2)             38 (80.9)         47 (23)
 Melasma with steroid-induced rosacea-like dermatitis                      2 (6.9)             27 (93.1)         29 (14.2)
 Compound nevus                                                           10 (37)               17 (63)          27 (13.2)
 Ephelides                                                                   0                  16 (100)         16 (7.8)
 Acne-induced postinflammatory hyperpigmentation                          6 (46.2)              7 (53.8)         13 (6.4)
 Blue nevus                                                               5 (41.7)              7 (58.3)         12 (5.9)
 Seborrhoeic keratosis                                                    6 (54.5)              5 (45.5)         11 (5.4)
 Junctional nevus                                                         4 (44.4)              5 (55.6)          9 (4.4)
 Periorbital hyperpigmentation                                            4 (57.1)              3 (42.9)          7 (3.4)
 Solar lentigo                                                             2 (40)                3 (60)           5 (2.5)
 Dermatosis papulosa nigra                                                   0                  4 (100)            4 (2)
 Postinflammatory hyperpigmentation                                        2 (50)                2 (50)            4 (2)
 Clofazimine-induced pigmentation                                         2 (66.7)              1 (33.3)          3 (1.5)
 Discoid lupus erythematosus                                              2 (66.7)             1 (33.3%)          3 (1.5)
 Café-au-lait macule                                                       1 (50)                1 (50)            2 (1)
 Dermal nevus                                                              1 (50)                1 (50)            2 (1)
 Hori nevus                                                                  0                  2 (100)            2 (1)
 Peribuccal pigmentation of Brocq                                            0                  2 (100)            2 (1)
 Verrucous epidermal nevus                                                   0                  2 (100)            2 (1)
 Ashy dermatosis                                                             0                  1 (100)           1 (0.5)
 Lentigo simplex                                                             0                  1 (100)           1 (0.5)
 Nevus of Ota                                                             1 (100)                  0              1 (0.5)
 Nevus spilus                                                             1 (100)                  0              1 (0.5)
 Total                                                                   58 (28.4)             146 (71.6)          204



                                 Table 2. Dermoscopic Features of Facial Melanoses
          Diagnosis                                         Dermoscopic Features                               Percentage
 Acne-induced                     Brown structureless areas                                                       78.6%
 postinflammatory                 Brown reticular pattern                                                         64.3%
 hyperpigmentation
 Ashy dermatosis                  Blue gray pigmentation forming a curvilinear pattern                            100%
 Blue nevus                       Blue gray homogenous pattern                                                    100%
 Café-au-lait macule              Light brown reticular pattern                                                   100%
                                  Blue gray dots                                                                   50%
 Clofazimine induced              Coppery red background                                                          100%
 pigmentation                     Brown homogenous pattern                                                        66.7%
                                  Hem-like pattern                                                                66.7%
 Compound nevus                   Diffuse black homogenous pattern                                                51.9%
                                  Dark brown globular pattern                                                     18.5%
 Dermal nevus                     Cobblestone pattern, Tan structureless area                                     100%
 Dermatosis papulosa nigra        Fissures and ridges, milia-like cysts, moth-eaten border                        100%
 Discoid lupus                    Follicular keratotic plugs, dark brown pigmentation                             100%
 erythematosus                    Perifollicular halo, White structureless areas                                  100%
                                  Telangiectatic vessels                                                          100%
 Ephelides                        Brown reticular pattern with moth-eaten border                                  100%
                                  Dark brown dots                                                                 93.8%
 Hori nevus                       Bluish brown blotch                                                             100%

                                                                                                              Table 2 continues



Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                3
                        Table 2. Dermoscopic Features of Facial Melanoses. (continued)
          Diagnosis                                      Dermoscopic Features                                    Percentage
 Junctional nevus               Dark brown reticular pattern                                                        55.6%
                                Light brown reticular pattern, Interspersed brown dots                              33.3%
 Lentigo simplex                Brown reticular pattern with moth-eaten border                                      100%
 Melasma                        Arciform structures                                                                 85.1%
                                Telangiectasia                                                                       83%
                                Dark brown to bluish gray reticular pattern                                         61.7%
                                Light brown reticular pattern                                                       44.3%
 Melasma with steroid-          Telangiectasias                                                                     100%
 induced rosacea-like           Arciform structures                                                                 93.1%
 dermatitis                     Dark brown to bluish gray reticular pattern                                         79.3%
                                Light brown reticular pattern                                                       55.2%
                                Dilated tortuous branched vessels giving a polygonal appearance                     48.3%
                                Terminal hair                                                                       17.2%
 Nevus of Ota                   Blue gray pigmentation forming a curvilinear pattern                                100%
 Nevus spilus                   Light brown reticular pattern                                                       100%
 Peribuccal pigmentation of     Dark brown reticular pattern                                                        100%
 Brocq                          Dark brown hem-like pattern                                                          50%
 Periorbital                    Dark brown reticular pattern                                                        100%
 hyperpigmentation              Dark brown hem-like pattern                                                         100%
                                Cobblestone pattern                                                                 57.1%
 Postinflammatory               Dark brown reticular pattern                                                         50%
 hyperpigmentation              Moth-eaten borders                                                                   50%
                                Dark brown homogenous pattern                                                        25%
                                Dark brown peripheral reticular pattern with central hypopigmentation                25%
 Seborrheic keratosis           Milia-like cysts                                                                    63.6%
                                Fissures and ridges                                                                 54.5%
                                Comedo-like openings                                                                36.4%
                                Fingerprint-like structures                                                         27.3%
 Solar lentigo                  Brown reticular pattern, Fingerprint-like structures                                 80%
                                Moth-eaten border                                                                    80%
                                Brown structureless homogenous pigmentation                                          80%
                                                                                                                     80%
 Verrucous epidermal nevus      Large brown circles with hyperchromic brown edge surrounding a                       50%
                                hypochromic areata
                                Exophytic structures                                                                 50%




Figure 1. Dermoscopic image. (A) acne-induced post inflammatory hyperpigmentation showing homogenous dark brown pattern on a red-
dish background. (B) trauma-induced postinflammatory hyperpigmentation showing reticular dark brown pattern with dark brown dots.



4                                                                    Original Article | Dermatol Pract Concept. 2022;12(1):e2022030
  Figure 2. Dermoscopic image revealing blue gray pigmentation forming a curvilinear pattern (square). (A) ashy dermatosis.
  (B) nevus of Ota.




Figure 3. Dermoscopic image. (A) café-au-lait macule displaying a dark brown reticular pattern (rectangle) with dark brown dots (circle). (B)
nevus spilus showing a reticular pattern (rectangle) with follicular sparing and perifollicular accentuation (circle).



and nevus spilus. In addition to the reticular pattern, the café-       nevus revealed large brown circles with a hyperchromic
au-lait macule displayed dark brown dots and perifollicular             brown edge surrounding a hypochromic area.
accentuation was observed in nevus spilus (Figure 3).                       Melasma and melasma with steroid-induced rosacea-like
    Clofazimine-induced pigmentation, peribuccal pigmen-                dermatitis were classified into epidermal, dermal, and mixed
tation of Brocq, and periorbital pigmentation revealed a                types based on dermoscopic findings. The epidermal type
reticular and hem-like pattern of pigmentation on dermos-               was characterized by the presence of scattered islands of a
copy (Figure 4). The background was coppery red in clofaz-              light brown reticular network and the dermal type by dark
imine-induced pigmentation but not in the other two condi-              brown to bluish gray irregular pigment network and arciform
tions (Figure 4). Hori nevus showed a speckled bluish brown             structures. The mixed type had presence of epidermal and
pattern of pigmentation (Figure 5), and verrucous epidermal             dermal features (Figure 6).There were 8 (17.0%) epidermal,



Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                             5
                                                             Figure 4. Dermoscopic picture showing dark brown
                                                             hem-like pigment pattern (rectangle). (A) clofazi-
                                                             mine-induced pigmentation on a coppery background.
                                                             (B) peribuccal pigmentation of Brocq. (C) periorbital
                                                             hyperpigmentation.




    Figure 5. Dermoscopic image. (A) Hori nevus showing speckled bluish brown pigmentation. (B) verrucous epider-
    mal nevus showing large brown circles with hyperchromic brown edge surrounding a hypochromic area (rectangle).




6                                                               Original Article | Dermatol Pract Concept. 2022;12(1):e2022030
Figure 6. Clinical, Wood lamp examination, and dermoscopic images in epidermal, dermal, and mixed melasma. (A) epidermal melasma show-
ing faint hyperpigmented macules in bilateral malar region showing accentuation. (B) on Wood lamp examination. (C) light brown reticular
pattern (rectangle) and brown dots (circle) on dermoscopy.(D) Dermal melasma with dark brown hyperpigmented macules on the forehead.
(E) malar region showing masking of pigmentation on Wood lamp examination. (F) dark brown irregular pigment network (rectangle), arci-
form structures (circle) and telangiectasia (pentagon) on dermoscopy. (G) Mixed melasma displaying light brown hyperpigmented macules on
periorbital and forehead regions displaying accentuation on forehead. (H) masking on malar region on Wood lamp examination. (I) Dermosco-
py shows light brown (rectangle) and dark brown (hexagon) pigment networks, arciform structures (diamond), and telangiectasia (pentagon).




Table 3. Correlation Between Wood lamp and Dermoscopic Findings in Melasma and Melasma with
                             Steroid-Induced Rosacea-Like Dermatitis
                                                           Melasma
                                                         Dermoscopy
                                                                                                           Χ2- value        P value
    Wood’s lamp             Epidermal             Dermal              Mixed                 Total
 Epidermal                   8 (17%)              0 (0%)             1 (2.1%)            9 (19.1%)           60.08           0.000
 Dermal                       0 (0%)            13 (27.7%)            0 (0%)            13 (27.7%)
 Mixed                        0 (0%)             8 (17%)            17 (36.2%)          25 (53.2%)
 Total                       8 (17%)            21 (44.7%)          18 (38.3%)
 Kappa statistics = 0.701, P = 0.0001 (significant)

                                                                                                                         (continues)


Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                         7
Table 3. Correlation Between Wood lamp and Dermoscopic Findings in Melasma and Melasma with
                       Steroid-Induced Rosacea-Like Dermatitis (continued)
                              Melasma With Steroid-Induced Rosacea-Like Dermatitis
                                                        Dermoscopy
                                                                                                           Χ2 value         P value
    Wood’s lamp            Epidermal             Dermal               Mixed                Total
 Epidermal                  6 (20.7%)             0 (0%)              0 (0%)            6 (20.7%)            34.00           0.000
 Dermal                      0 (0%)             8 (27.6%)            2 (6.9%)          10 (34.5%)
 Mixed                       0 (0%)             5 (17.2%)           8 (27.6%)          13 (44.8%)
 Total                      6 (20.7%)          13 (44.8%)          10 (34.5%)
 Kappa statistics = 0.628, P = 0.0001 (significant)




Figure 7. Clinical, Wood lamp examination and dermoscopic images in epidermal, dermal, and mixed melasma with steroid-induced rosa-
cea-like dermatitis. (A) Epidermal melasma with steroid-induced rosacea-like dermatitis showing faint hyperpigmented macules in bilateral
malar region. (B) accentuation on Wood lamp examination. (C) light brown reticular pattern (rectangle), dilated tortuous vessels (oval)
forming a polygonal pattern (diamond) on dermoscopy. (D) Dermal melasma with steroid-induced rosacea-like dermatitis with dark brown
hyperpigmented macules on forehead and malar region and erythema on bridge of nose. (E) masking of pigmentation on Wood lamp exam-
ination. (F) dark brown homogenous pigmentation (rectangle), dilated tortuous vessels (telangiectasia) forming a polygonal pattern (oval)
on dermoscopy. (G) Mixed melasma displaying light brown hyperpigmented macules on malar region with faint erythema displaying accen-
tuation on malar. (H) masking on the forehead region on Wood lamp examination. (I) Dermoscopy shows light brown (hexagon) and dark
brown (rectangle) pigment network with red structureless areas (oval).



8                                                                        Original Article | Dermatol Pract Concept. 2022;12(1):e2022030
21 (44.7%) dermal and 18 (38.3%) mixed types of melasma.         ies done in India found a substantial degree of agreement
A similar pattern was observed in melasma with steroid-in-       between Wood’s lamp and dermoscopic findings in melasma.
duced rosacea-like dermatitis: epidermal (6, 20.7%), dermal      Dharni et al [7] found correlation between the two techniques
(13, 44.8%), mixed (10, 34.5%).                                  in 56.25% of patients and the degree of agreement was sta-
   The degree of agreement between Wood lamp and der-            tistically significant (k = 0.813, P = 0.0001). Manjunath et al
moscopic findings was found to be substantial as analyzed        [8] also found a good degree of correlation (k = 0.833, P =
by kappa statistics (Table 3). Of the 8 lesions considered as    0.0001). In our study too, the degree of agreement was sig-
epidermal type by dermoscopy, the examination agreement          nificant (k = 0.701, P = 0.000). However, while the degree of
under Wood lamp was 100%. Of the 21 considered dermal            agreement was 100% for epidermal type, it was only 44.8%
by dermoscopy, the agreement with Wood lamp was only             for dermal melasma. The discrepancies could be attributed
44.8%. And of the 18 considered mixed by dermoscopy, the         to better visualization of arciform structures and dark brown
agreement was 94.4% with Wood lamp examination.                  to bluish gray irregular pigment network in dermal melasma
   Regarding melasma with steroid-induced rosacea-like           with dermoscopy.
dermatitis, 6 cases were classified as epidermal, 13 as der-        In our setting, melasma with steroid-induced rosacea-like
mal and 10 as mixed type. The agreement with Wood lamp           dermatitis is frequently encountered [3]. The main dermo-
examination was 100% for epidermal, 61.5% for dermal             scopic features identified were light to dark brown reticu-
and 80.0% for mixed type. In addition, dermoscopy revealed       lar pigment network, arcuate structures, dilated tortuous
follicular sparing with perifollicular accentuation (96.6%),     branched vessels giving a polygonal appearance and terminal
arcuate structures (93.1%), dilated tortuous branched vessels    hairs. Jakhar et al [11] in their case report on topical ste-
giving a polygonal appearance (44.8%) and terminal hairs         roid dependent/damaged face discovered dilated tortuous
(10.3%) (Figure 7).                                              branched vessels interconnecting with each other to form a
   Although the two cases of dermal nevus showed different       polygonal pattern on dermoscopy. In addition, white struc-
patterns of autofluorescence on Wood lamp examination,           tureless areas, yellowish areas and coarse terminal hairs were
there were no differences detected in dermoscopic exam-          also visible [11]. According to them, white structureless areas
ination. The three cases of dermal periorbital hyperpigmen-      correspond to dermal atrophy. We did not encounter white
tation revealed dark brown reticular and hem-like pattern        structureless areas in our study indicating that this could be
on dermoscopy while the epidermal cases showed cobble-           an incidental finding. We also found correlation between
stone pattern in addition to the above features. Dark brown      Wood lamp and dermoscopic classification of melasma
blotches, hem-like pattern on a coppery red background were      with steroid-induced rosacea-like dermatitis (k = 0.628, P =
observed in epidermal clofazimine-induced pigmentation           0.0001), which has not yet been reported in the literature.
while blotches were not seen in dermal clofazimine-induced       Here again, while agreement was 100% in epidermal type,
pigmentation.                                                    it decreased to 61.5% for dermal and 80% for mixed type.
                                                                 Thus, while Wood lamp examination may help to differen-
                                                                 tiate epidermal melasma from other types of conditions, it
Conclusions
                                                                 may not be so accurate for dermal or mixed melasma with
In our study, melasma was the most frequent diagnosis            steroid-induced rosacea-like dermatitis.
followed by melasma with steroid-induced rosacea-like               In this study, we had one patient with ashy dermatosis and
dermatitis. Epidermal melasma was characterized by light         one with nevus of Ota. The dermoscopic findings in both the
brown reticular network, dermal by dark brown to bluish          cases were similar; blue gray pigmentation forming a curvilin-
gray irregular pigment network and arciform structures and       ear pattern. Gray dots and globules having an irregular linear
mixed by features of both epidermal and dermal types. Nan-       arrangement in ashy dermatosis has also been reported by
jundaswamy et al [9] also observed scattered islands of brown    Elmas et al [12]. This arrangement has been named as broken
reticular network in epidermal melasma. Dermal melasma           lines and semi-arcuate structures appearing as Chinese letters
showed uniform skin involvement with dark brown to gray          by Vinay et al [13]. Blue gray pigmentation forming a curvi-
hyperpigmented irregular pigment network. Yalamanchili           linear pattern on dermoscopic examination of nevus of Ota
et al [10] also found light or dark brown, diffuse or patchy     has not yet been described in the literature. In the study done
reticular pigmentation in 95% of patients with melasma.          by Elmas et al [14], the most common dermoscopic findings
   Few studies have compared Wood lamp and dermoscopic           of nevus of Ota were brown and gray structureless areas hav-
findings in melasma. Tamler et al [6], in their study done in    ing a patchy distribution. They also observed white clods in
Brazil, found 44% agreement in epidermal melasma, 57%            a “four dots clod” arrangement. El-Kadiri et al [15] observed
in dermal melasma and 51% in mixed melasma. The degree           blue grayish structureless areas with iridescent reflections
of concordance was considered weak (k < 0.2). Two stud-          and white rosettes in their case report on nevus of Ota. A



Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                9
curvilinear pattern could be discerned in the dermoscopic         moscopy. Reticular and hem-like pattern of pigmentation was
image in their case report, although it was not mentioned by      observed on dermoscopy of clofazimine-induced pigmenta-
the authors. Whether a curvilinear pattern is a characteristic    tion, peribuccal pigmentation of Brocq and periorbital pig-
feature of nevus of Ota remains to be explored.                   mentation. Although the degree of agreement between Wood
     Dark brown blotches, hem-like pattern of pigmentation        lamp and dermoscopic findings were found to be statistically
on a coppery red background were observed on dermoscopic          significant in the different types of melasma and melasma
examination of patients with clofazimine-induced pigmen-          with steroid-induced rosacea-like dermatitis, the agreement
tation. We identified only one study that had evaluated           was higher for epidermal types and less for dermal and mixed
dermoscopic findings in clofazimine-induced pigmentation.         types. We recommend further studies exploring dermoscopic,
Chopra et al [16] described honeycomb pattern with yellow         Wood lamp and histological findings in all facial melanoses.
to white globules interspersed along a dark to skin-colored
background. To best of our knowledge, this is the first study
                                                                  References
identifying hem-like pattern of pigmentation in clofazi-
mine-induced pigmentation.                                         1. Patel A, Kubba R, Kubba A. Clinicopathological correlation of
     We had seven cases of periorbital hyperpigmentation              acquired hyperpigmentary disorders. Indian J Dermatol Venereol
                                                                      Leprol. 2013;79(3):367-375. DOI: 10.4103/0378-6323.110798.
out of which four displayed accentuation of pigmentation
                                                                      PMID: 23619441.
on Wood lamp examination. All cases showed dark brown
                                                                   2. Abdel-Naser M. The color of skin: gray diseases of the skin, nails,
reticular and hem-like pigmentation on dermoscopic exam-              and mucosa. Clin Dermatol. 2019;37(5):507-515. DOI:10.1016/j.
ination. The epidermal cases showed a cobblestone pattern             clindermatol.2019.07.011. PMID: 31896405.
in addition to the above features. Jage et al [17] evaluated       3. Amatya B, Jha AK, Shrestha S. Frequency of different types of
the dermoscopic findings in 50 patients with periorbital              facial melanoses referring to the Department of Dermatology and
                                                                      Venereology, Nepal Medical College and Teaching Hospital in
hyperpigmentation in 2018. The most common findings were
                                                                      2019, and assessment of their effect on health-related quality of
blotches, exaggerated pigment network, coarse speckled,
                                                                      life. BMC Dermatol. 2020;20(1):1-7. DOI: 10.1186/s12895-020-
fine speckled and globules. Skin changes included atrophy             00100-3. PMID: 32746823; PMCID: PMC7398190.
and exaggerated skin markings. We believe the hem-like pig-        4. Uitentuis S, Bekkenk M, van Geel N, de Rie M, Wolkerstorfer
mentation (increased pigmentation along the skin folds) seen          A. UV light set-ups for vitiligo photography, a comparative
on dermoscopy corresponds to exaggerated skin markings.               study on image quality and ease of use. J Eur Acad Derma-
                                                                      tol. 2019;33(10):1971-1975. DOI:10.1111/jdv.15666. PMID:
The exaggerated skin markings imply an atopic diathesis,
                                                                      31077457; PMCID: PMC6851740.
post-steroid abuse or constitutional type of periorbital hyper-
                                                                   5. Lu QS, Chen X, Wang S, Xu SS, Wu T, Jiang G. Dermoscopy com-
pigmentation [17].                                                    bined with Wood lamp, a diagnostic alternative for five pigmented
     There were some notable limitations in the study. As it          lesions on the face: an observational study. Chin Med J. 2020;
was a cross-sectional study, we could not obtain longitudinal         133(22):2771-2772. DOI: 10.1097/CM9.0000000000001009.
data. This was especially true for discoid lupus erythematosus        PMID: 32804732; PMCID: PMC7725530.
                                                                   6. Tamler C, Fonseca R, Pereira F, et al. Classification of melasma
and ephelides, which have waxing and waning courses. Our
                                                                      by dermoscopy: comparative study with Wood’s lamp. Surg Cosm
hospital-based study also may be not??? representative of the
                                                                      Dermatol. 2009;1(3):115-119.
general population.                                                7. Dharni R, Madke B, Singh A. Correlation of clinicodermatoscopic
     Another limitation of our study is the relatively small          and Wood’s lamp findings in patients having melasma. Pigment
sample size and the lack of histopathological correlation with        Int. 2018;5(2):91-95. DOI: 10.4103/Pigmentinternational.Pig-
dermoscopic examination. As this study took place during the          mentinternational_
                                                                   8. Manjunath K, Kiran C, Sonakshi S, Agrawal R. Melasma: Through
peak of the COVID-19 epidemic in Nepal, this affected the
                                                                      the eye of a dermoscope. Int J Res Dermatol. 2016;2(4):113-117.
sample size. Furthermore, most patients chose not to undergo
                                                                      DOI: 10.18203/issn.2455-4529.IntJResDermatol20164071.
an invasive procedure like biopsy for histopathological con-       9. Nanjundaswamy B, Joseph J, Raghavendra K. A clinico dermo-
firmation. We recommend future studies exploring correla-             scopic study of melasma in a tertiary care center. Pigment Int.
tion between dermoscopic and histopathological findings in            2017;4(2):98-103. DOI: 10.4103/2349-5847.219678
all facial melanoses as dermoscopic information provided to       10. Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological
                                                                      Study and Quality of Life Assessment in Melasma. Indian J
pathologist can improve diagnostic accuracy.
                                                                      Dermatol. 2015;60(5):519. DOI: 10.4103/0019-5154.164415.
     The most frequent diagnoses in our study were melasma,
                                                                      PMID: 26538717; PMCID: PMC4601438.
melasma with steroid-induced rosacea-like dermatitis and          11. Jakhar D, Kaur I. Dermoscopy of topical steroid damaged/
various types of naevi. Dermoscopy of ashy dermatosis and             dependent face. Indian Dermatol Online J. 2018;9(4):286-287.
nevus of Ota revealed blue gray pigmentation forming a cur-           DOI: 10.4103/idoj.idoj_301_17. PMID: 30050829; PMCID:
vilinear pattern. Café-au-lait macule and nevus spilus revealed       PMC6042197.

light brown reticular pattern with follicular sparing on der-



10                                                                   Original Article | Dermatol Pract Concept. 2022;12(1):e2022030
12. Elmas ÖF, Acar EM, Kilitçi A. Dermoscopic diagnosis of ashy       15. El Kadiri S, Bay HB, Chaoui R, Douhi Z, Elloudi S, Mernissi FZ.
    dermatosis: A retrospective study. Indian Dermatol Online J.          A new dermoscopic finding in Ota nevus. Our Dermatol Online.
    2019;10(6):639-643. DOI: 10.4103/idoj.IDOJ_517_18. PMID:              2020;11(e):e11.1-e11.2. DOI: 10.7241/ourd.2020e.11.
    31807441; PMCID: PMC6859771.                                      16. Chopra A, Mitra D, Agarwal R, Saraswat N, Talukdar K, Solanki
13. Vinay K, Bishnoi A, Parsad D, Saikia UN, Sendhil Kumaran M.           A. Correlation of dermoscopic and histopathologic patterns in
    Dermatoscopic evaluation and histopathological correlation            leprosy: A pilot study. Indian Dermatol Online J. 2019;10(6):663-
    of acquired dermal macular hyperpigmentation. Int J Derma-            668. DOI: 10.4103/idoj.IDOJ_297_18. PMID: 31807445; PM-
    tol. 2017;56(12):1395-1399. DOI: 10.1111/ijd.13782. PMID:             CID: PMC6859759.
    28971471.                                                         17. Jage M, Mahajan S. Clinical and dermoscopic evaluation of
14. Elmas ÖF, Kilitçi A. Dermoscopic Findings of Nevus of Ota. Bal-       periorbital hyperpigmentation. Indian J Dermatopathol Diagn
    kan Med J. 2020;37(2):116-118. DOI: 10.4274/balkanmedj.gale-          Dermatol. 2018;5(1):42-47. DOI: 10.4103/ijdpdd.ijdpdd_2_18.
    nos.2019.2019.11.46. PMID: 31852034; PMCID: PMC7094188.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022030                                                                         11
