Dermoscopy in Monitoring and Predicting Therapeutic Response … · 2020. 11. 9. · nus,...

REVIEW

Dermoscopy in Monitoring and PredictingTherapeutic Response in General Dermatology (Non-Tumoral Dermatoses): An Up-To-Date Overview

Enzo Errichetti

Received: September 2, 2020 / Published online: October 8, 2020� The Author(s) 2020

ABSTRACT

Besides the well-known use in supporting thenon-invasive diagnosis of non-tumoral der-matoses (general dermatology), dermoscopy hasbeen shown to be a promising tool also in pre-dicting and monitoring therapeutic outcomesof such conditions, with the consequentimprovement/optimization of their treatment.In the present paper, we sought to provide anup-to-date overview on the use of dermoscopyin highlighting response predictor factors andevaluating therapeutic results in the field ofgeneral dermatology according to the currentliterature data. Several dermatoses may some-how benefit from such applications, includinginflammatory conditions (psoriasis, lichen pla-nus, dermatitis, granulomatous conditions,erythro-telangiectatic rosacea, Zoon balanitisand vulvitis, cutaneous mastocytosis, morpheaand extra-genital lichen sclerosus), pigmentarydisorders (vitiligo and melasma) and infectiousdermatoses (scabies, pediculosis, demodicosisand viral warts).

Keywords: Dermatoscopy; Dermoscopy;Monitoroscopy; Outcomes; Treatment; Therapy

Key Summary Points

Why carry out the study?

Dermoscopy has recently been shown tobe a promising tool in predicting andmonitoring therapeutic outcomes of non-tumoral dermatoses (generaldermatology).

Data on such a novel application is,however, sparse and no detailed reviewpaper on this topic exists.

What was learned from the study?

We provided an up-to-date overview onthe use of dermoscopy in highlightingresponse predictor factors and evaluatingtherapeutic results in the field of generaldermatology according to the currentliterature data.

Dermoscopy may be of aid in theimprovement/optimization of themanagement of several non-tumoraldermatoses by highlighting possibleclinically subtle/invisible responsepredictors (positive or negative) andmonitoring the lesions’ changes at asubclinical level.

E. Errichetti (&)Institute of Dermatology, ‘‘Santa Maria DellaMisericordia’’ University Hospital, Udine, Italye-mail: [email protected]

Dermatol Ther (Heidelb) (2020) 10:1199–1214

https://doi.org/10.1007/s13555-020-00455-y

http://crossmark.crossref.org/dialog/?doi=10.1007/s13555-020-00455-y&domain=pdf

https://doi.org/10.1007/s13555-020-00455-y

DIGITAL FEATURES

This article is published with digital features tofacilitate understanding of the article. You canaccess the digital features on the article’s asso-ciated Figshare page. To view digital features forthis article go to https://doi.org/10.6084/m9.figshare.12985496.

INTRODUCTION

Over the last few decades, the dermoscope hasbecome an invaluable tool in dermatologicaldaily clinical practice thanks to its ability toshow findings not visible to the naked eye,thereby often being referred to as the derma-tologist’s ‘‘stethoscope’’ [1, 2]. Although it istraditionally used in the assessment of bothmelanocytic and non-melanocytic proliferativelesions as well as hair disorders [1–3], der-moscopy is increasingly gaining appreciation inthe spectrum of non-tumoral skin conditions(i.e. general dermatology), including inflam-matory, pigmentary, infectious and infiltrativedermatoses, with consequent reduction in thenumber of cases requiring biopsy [3–12]. In thisregard, such a technique has been shown tohave further applications apart from assistingthe clinical diagnosis, including predicting andmonitoring therapeutic outcomes, with theconsequent improvement/optimization of themanagement of non-tumoral dermatoses [3–7].

The aim of this paper is to provide an up-to-date overview on the use of dermoscopy inhighlighting response predictor factors andevaluating treatment results in the field ofgeneral dermatology according to the currentliterature data.

An electronic search was performed inAugust 2020 by using the PubMed database. Inthe first step the search terms were ‘‘predictors’’AND ‘‘dermoscopy’’ (OR ‘‘dermatoscopy’’ OR‘‘videodermoscopy’’); ‘‘predictor factors’’ AND‘‘dermoscopy’’ (OR ‘‘dermatoscopy’’ OR ‘‘video-dermoscopy’’); ‘‘monitoring’’ AND ‘‘der-moscopy’’ (OR ‘‘dermatoscopy’’ OR‘‘videodermoscopy’’); ‘‘follow-up’’ AND ‘‘der-moscopy’’ (OR ‘‘dermatoscopy’’ OR

‘‘videodermoscopy’’). In the second step thesearch protocol included specific diagnoses i.e.‘‘psoriasis’’ AND ‘‘dermoscopy’’ (OR ‘‘der-matoscopy’’ OR ‘‘videodermoscopy’’). Addition-ally, pertinent references not identified bysearch engine and retrieved from articles/bookswere also taken into account. All studies writtenin English dealing with treatment outcomesprediction and monitoring of non-tumoral dis-eases (including inflammatory, pigmentary,infiltrative and infectious dermatoses) wereanalysed, including controlled studies, caseseries, case reports and reviews. Articlesaddressing hair, nail and mucosal diseases wereexcluded.

Tables 1 and 2 summarise dermoscopic dataon response predictor factors and clues intreatment follow-up of non-tumoral der-matoses, including inflammatory, pigmentaryand infectious diseases. This article is based onpreviously conducted studies and does notcontain any studies with human participants oranimals performed by the author.

Inflammatory Diseases

PsoriasisPsoriasis is surely the most studied inflamma-tory condition from a dermoscopic point ofview [13]. Its hallmarks on dermoscopy includeuniform dotted/globular vessels and diffusewhite scales; however, haemorrhagicdots/globules are also commonly seen and areoften related to scratching [3–7], being foundmore frequently in areas in which psoriasis istypically itchy, such as scalp and legs [14].Notably, at higher magnification (videoder-moscopy), psoriatic dilated vessels usually showa bushy appearance [3–6].

Several studies have demonstrated thatvideodermoscopic follow-up of psoriasis mayfacilitate treatment response assessment byshowing changes in vessels morphology anddiameter [15–23]. In particular, studies evaluat-ing under high magnification (from 9100 to9300) psoriatic plaques successfully treatedwith either topical [15–18] or systemic [19–23]therapies revealed a progressive reduction ofvessels’ tortuosity and diameter over the time

1200 Dermatol Ther (Heidelb) (2020) 10:1199–1214

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https://doi.org/10.6084/m9.figshare.12985496

Table 1 Dermoscopic data on response predictor factors and clues in treatment follow-up of inflammatory diseases

Disease Main dermoscopicdiagnostic clues

Dermoscopic response predictors Clues in treatment follow-up Type ofsupportingevidence

Psoriasis Uniformdotted/globularvessels

Diffuse white scales

Haemorrhagic dots appearing in the first2/4 weeks of treatment with biologics areassociated with a good outcome

Baseline globular and dotted vessels arerespectively associated with bad and goodresponse to both narrowband ultraviolet Bphototherapy and topicalcalcipotriol/betamethasone therapy

Persistence of vessels at the end of topicalcalcipotriol/betamethasone therapy isrelated to an earlier relapse

Reduction of vessels’ diameter andtortuosity at high magnification(videodermoscopy) during effective(topical or systemic) therapies

Early (subclinical) detection of diseaserecurrence (appearance of dotted vessels)

Early (subclinical) detection of steroid-induced skin atrophy (appearance oflinear/reticular vessels)

Case series[15–26]

Review/book(mechanism-basedreasoning)[3]

Lichen planus Wickham striae – Monitoring stage evolution of lesions undertreatment

Likelihood of post-inflammatorypigmentation persistence (dots anddiffuse pigmentation are related to alonger and shorter course, respectively)

Review/book(mechanism-basedreasoning)[3–8]

Case reports[27]

Dermatitis Clustered dottedvessels

Diffuse white scales

– Reduction of crusts and scales along withvascular pattern normalization duringdupilumab treatment

Early (subclinical) detection of steroid-induced skin atrophy (appearance oflinear/reticular vessels)

Case series [28]

Granulomatousdermatoses

Orange structurelessareas

Indirect prediction of therapeutic outcomesin granuloma annulare by facilitating therecognition of the histological subtype

Disappearance of vessels and orange areasduring effective therapies


Case series [30]

Rosacea(erythro-telangiectatic)

Linear vesselsarranged inpolygonalnetworks (vascularpolygons)

Baseline protruding follicular plugs areassociated with a better response to topicalivermectin therapy

Reduction of vessels as a marker of lasertherapy efficacy

Case series(personalobservation)

Zoon balanitisand vulvitis

Orange areas

Focused curvedvessels

– Normalization of dermoscopic vascularpattern as a marker of therapeuticefficacy

Case report[37]

Cutaneousmastocytosis

Coarse brownnetwork (urticariapigmentosa)

Yellow-orange areas(mastocytoma)

Diffuse light-browndiscoloration and/or brown network(mastocytoma)

‘‘Reticular’’ vascular pattern (along with serumtryptase levels and plaque-type lesions) isassociated with the need for a maintainedantimediatior therapy

Monitoring stage evolution of lesions(mastocytoma)

Case series [38]


Morphea Ill-defined dull whiteglobules

– Higher accuracy in monitoringinflammation and fibrosis regression byshowing vessels and white areasreduction, respectively

Case-controlledstudy [41]

Dermatol Ther (Heidelb) (2020) 10:1199–1214 1201

up to a complete normalization (i.e. capillarieswith diameters B 25 lm [23]), although thismay sometimes not be reached despite clinicalhealing [23]. The possibility to evaluate vascular

changes in psoriasis has a double practicalimplication: (I) early assessment of treatmentresponse, as reduction in vessels’ diameter andtortuosity may already be seen in the first weeks

Table 1 continued



Lichen sclerosus(extra-genital)

Bright white areas

Follicular plugs

– Higher accuracy in monitoring

inflammation and fibrosis

regression by showing vessels and

white areas reduction, respectively

Case-controlledstudy [41]

Table 2 Dermoscopic data on response predictor factors and clues in treatment follow-up of pigmentary and infectiousdiseases



Vitiligo Milky/bright whitestructureless areaswith sharp andconvex margins

White hairs(leukotrichia)

Perifollicularpigmentation

Baseline white hairs are related to poor response inboth non-segmental vitiligo treated with excimerlaser and segmental vitiligo treated withphototherapy, laser or surgery

Baseline perifollicular pigmentation is associatedwith a good outcome in non-segmental vitiligotreated with narrowband ultraviolet Bphototherapy

Selection of the most appropriate therapy accordingto the lesion stage (active vs stable)

Assessment of initial therapeuticresponse by showing subclinicalpigmentation


Melasma Light/dark brown, greyor bluepseudonetwork

Prediction of therapeutic response by facilitating therecognition of lesions deepness

Significant dermoscopic vascular componentsupports the use of pulsed-dye laser

Assessment of initial therapeuticresponse by showing attenuation/regression of pigmentary andvascular structures


Scabies ‘‘Delta-wing jet withcontrail’’ sign

– Absence of mite migration 24 hafter an effective treatment

Progressive degradation of the mitewith replacement with anamorphous material after aneffective treatment

Case series[55, 56]

Pediculosis Evidence of louse andnits

– Disappearance of parasites and viablenits after an appropriate therapy

Case series [57]

Case series [58]

Demodicosis Protruding follicularplugs

– Reduction of protruding follicularplugs as a marker of therapyefficacy

Case report [59]

Warts Dermatoglyphic/skinfurrows interruption

Thrombosed capillaries(common warts)

Dotted vessels withwhite halos (planewarts)

– Assessment of complete healing byshowing disappearance ofsubclinical findings



of therapy [15–23], and (II) evaluation of per-sistence of vascular abnormalities in clinicallyhealed lesions, as their presence has been sup-posed to be related to a higher tendency torelapse [22].

Interestingly, recent studies showed thateven hand-held dermoscopy (910 magnifica-tion) may be of aid in treatment outcomesassessment in plaque-type psoriasis [24–26].Specifically, the appearance of haemorrhagicdots in the first 2/4 weeks of treatment is apredictor of subsequent response to biologicalagents [24], while the baseline evidence ofglobular and dotted vessels has respectivelybeen related to a negative and positive responseto both narrowband ultraviolet B phototherapy[25] and calcipotriene/betamethasone aerosolfoam (Fig. 1) [26]. Additionally, regarding thislast therapy, relapse is strongly associated withthe persistence of vascular structures (eitherdotted or globular vessels) on dermoscopy atthe end of the therapy when considering bothlesions regardless of degree of improvement andlesions reaching a complete/nearly completeclinical healing [26]. Accordingly, it has beensuggested that a ‘‘dermoscopic healing’’ wouldbe more advisable than a mere ‘‘clinical healing’’in order to ensure a longer response retention inpsoriasis treated with calcipotriene/betametha-sone aerosol foam [26].

Finally, hand-held dermoscopy is also help-ful in early detection of both disease recurrence

(as dermoscopic changes occur prior to clinicalworsening) [24] and steroid-induced skin atro-phy (by showing linear/reticular vessels beforetelangiectasias become clinically apparent)(Fig. 2) [3].

Lichen PlanusThe presence of Wickham striae on dermoscopyis a pathognomonic sign of lichen planus [3–8].They usually appear as intersecting crossingwhite lines forming a sort of network, yet othermorphologies (e.g. linear, radial, annular andround) and colours (i.e. yellow and blue-white)

Fig. 1 Clinical picture of a psoriatic plaque on the rightleg (white square) at baseline (a), with correspondingdermoscopy image showing presence of uniform globularvessels (better visible in inset) and diffuse white scaling (b).Clinical view of the same lesion after 4 weeks of therapywith calcipotriene plus betamethasone dipropionate

aerosol foam showing limited improvement (Local Psori-asis Severity Index improvement\ 50%) (c). (FromErrichetti E, et al. Dermatol Ther (Heidelb)2020;10:757–67)

Fig. 2 Dermoscopy of a psoriatic plaque after prolongeduse of topical steroid reveals linear vessels (arrow)suggesting that skin atrophy has initiated, though it isnot visible yet on clinical examination


are also seen less commonly [3–8]. Additionalfindings include (I) dotted, globular and/orlinear vessels, mainly detectable at the periph-ery of the lesion; (II) white/yellow dots; and (III)pigmented structures (dots, globules and/orreticular or cloud-like areas) [3–8].

Although all the aforementioned findingsmay sometimes coexist in a single lesion, der-moscopic patterns of lichen planus usually varyaccording to disease stage (Fig. 3), with earlypapules usually showing subtle Wickham striaeover a reddish background and mature lesionsdisplaying well-represented Wickham striae andperipheral vessels [3–8]. Both of these structurestend to fade over time, concomitantly to thegradual appearance of pigmented structures,and in long-standing lesions, pigmentary

findings are often the only visible clue [3–8].Accordingly, dermoscopy may be useful toaccurately monitor disease stage evolution oflesions under treatment [8].

Additionally, dermoscopic examination mayalso be used to assess the likelihood of post-in-flammatory pigmentation persistence, withhomogeneous, structureless and light brownareas devoid of granularity being correlatedwith a shorter duration and granular pigmen-tation being associated with a longer course(Fig. 4) [27].

DermatitisThe dermoscopic pattern of dermatitis variesaccording to the disease stage, even thoughoverlaps are possible [3–8]. In particular, yellow

Fig. 3 Dermoscopic pattern of lichen planus variesaccording to disease stage: subtle Wickham striae over areddish background are seen in early stages (a), whilemature and long-standing lesions respectively display well-

represented Wickham striae along with peripheral dot-ted/linear vessels (b) and pigmented structures withWickham striae and vascular remnants (c)

Fig. 4 Post-inflammatory pigmentation in lichen planus may feature two dermoscopic patterns, i.e. granular pigmentation(a) and homogeneous brown area (b), respectively associated with a longer and shorter persistence


serocrusts and dotted vessels distributed inclusters or randomly are typically seen inacute/subacute phases, while more or less uni-form dotted vessels surrounded by a white haloare the main dermoscopic features in chronicphases (lichenification) [3–8]. Haemorrhages arealso seen quite commonly as a result of intenseitching [3–8].

A recent study demonstrated that atopicdermatitis treated with a 16-week course ofdupilumab displayed a remarkable reduction ofcrusts and scales along with vascular patternnormalization on dermoscopic examinationcompared to baseline, thereby making der-moscopy a useful tool to assess subclinicalimprovement in this condition [28]. Notably,such dermoscopic changes seemed to occurconcomitantly with objective [EASI (EczemaArea and Severity Index) score] and subjective[P-NRS (Peak Pruritus Numerical Rating Scale)and DLQI (Dermatology Life Quality Index)scores] clinical improvement [28].

Moreover, as a result of the common use oftopical steroids in dermatitis, dermoscopy playsa significant role in preventing steroid-inducedskin atrophy by showing subclinical early signs,i.e. linear and/or reticular vessels [3].

Granulomatous DermatosesThe dermoscopic hallmark of granulomatousskin diseases is the presence of focal or diffuseorange structureless areas histologically corre-sponding to compact dermal granulomas,although such structures may be sometimesabsent (i.e. deeply located granulomas or pres-ence of remarkable epidermal changes) and arealso seen in other conditions characterized bydense cell infiltrates or haemosiderin deposits inthe dermis [29]. Additional dermoscopic cluesmay also be found in each granulomatous der-matosis (i.e. focused vessels in sarcoidosis andlupus vulgaris, follicular plugs and peripheralwhite striae in leishmaniasis, blurred vessels ingranuloma annulare, yellow areas and serpigi-nous-branching vessels in necrobiosis lipoidicaand vascular polygons in granulomatous rosa-cea) [29].

In general, dermoscopic examination may beof aid in treatment monitoring of granuloma-tous skin conditions by showing disappearance

of vascular and non-vascular findings, especiallyorange areas as they are a marker for the pres-ence of compact granulomatous infiltrate in thedermis (Fig. 5) [29, 30]. However, a recent studyemphasized that such dermoscopic structuresmay persist despite treatment in sarcoidosis,likely because of an incomplete efficacy oftherapies with persistence of some degree ofsubclinical inflammation [30].

Finally, dermoscopy may indirectly helppredict therapeutic outcomes in granulomaannulare by facilitating the recognition of thehistological subtype, i.e. palisading vs intersti-tial, respectively characterized by an orange andpinkish background (Fig. 6) [31]. Indeed, it hasbeen reported that the pathological patternmight influence the disease course/therapeuticresponse, with the palisading granuloma sub-type being associated with a more protractedcourse/significant resistance to treatments thanthe interstitial form [31].

Erythro-Telangiectatic RosaceaRecognizing this facial dermatosis on der-moscopy is a very straightforward task owing tothe presence of a highly specific feature, namelylinear vessels characteristically arranged inpolygonal networks (vascular polygons) [3–7].Additional, less specific findings includerosettes, follicular plugs, white-yellowish scales,pigmentation structures and dilated follicle[3–7].

Besides diagnostic purposes, dermoscopicassessment in erythro-telangiectatic rosaceamay also be helpful in monitoring post-treat-ment changes (with reduction of vascular andnon-vascular findings, especially when treatedwith lasers) and predicting therapeutic responseto topical treatments [32]. Indeed, according toa preliminary analysis on 20 patients sufferingfrom erythro-telangiectatic rosacea, the pres-ence of protruding follicular plugs is associatedwith a better response to an 8-week course ofivermectin 10 mg/g cream compared tometronidazole 1% gel used for the same timespan (personal observations) (Fig. 7). This wouldbe due to the possible active effect of the formertherapy on Demodex folliculorum as there is acorrelation between protruding follicular plugson dermoscopy and a higher mite density that


may be seen in rosacea (typically less than5 mites/cm2) [33].

Zoon Balanitis and VulvitisSuch conditions are dermoscopically character-ized by orange structureless areas and linear-curved vessels (including serpentine, chalice-shaped or convoluted) [34–37]. It has beenreported that normalization of the dermoscopicvascular pattern may indicate resolution of theactive phase despite the persistence of orangeareas on both dermoscopy and clinical

assessment (which may be evident for a longtime) (Fig. 8), thus avoiding overtreatment ofpatients and its possible consequences (e.g.steroid-induced skin atrophy) [37].

Cutaneous MastocytosisApart from facilitating diagnosis (by showingcoarse brown network or homogeneous brownareas), dermoscopy may also be of aid in ther-apeutic management of urticaria pigmentosa[38]. Indeed, although visible in a minority ofcases, the presence of a ‘‘reticular’’ vascular

Fig. 5 Dermoscopic assessment (a baseline; b after8 weeks of oral doxycycline therapy) in a case of granu-lomatous rosacea of the forehead allows one to see the

disappearance of orange areas (a arrows), histologicallyrelated to dermal granulomatous infiltrate fading

Fig. 6 Granuloma annulare shows a different dermoscopicbackground according to histological subtype, i.e. orangishin ‘‘palisading’’ variant (a) and pinkish in ‘‘interstitial’’variant (b), so dermoscopy may help in predicting

therapeutic outcomes as the pathological pattern mightinfluence the disease course/therapeutic response


pattern on dermoscopic assessment, along withserum tryptase levels and plaque-type lesions,was found to represent the best combination topredict the need for maintained antimediatiortherapy in one study [38]. Consequently, theauthors hypothesized that, in combination withother variables, dermoscopy could provideadditional help in the identification of patientsat risk for more severe symptoms [38].

Additionally, dermoscopic examination mayalso be used in the follow-up of mastocytoma aslesions in regressing/healing phases usually donot display yellow-orange areas (which aremore common in mature lesions) but only adiffuse light-brown discoloration and/or brownnetwork (Fig. 9) [39].

Fig. 7 Erythro-telangiectatic rosacea. Besides typical vas-cular polygons, this patient also shows protruding follicularplugs (arrows) on baseline dermoscopic examination (a);an optimal clinical response is reached after an 8-week

topical course of ivermectin, with disappearance ofprotruding plugs on dermoscopy (b)

Fig. 8 Zoon balanitis. Baseline dermoscopic assessment(a) reveals linear-curved vessels (better visible in the upperright inset). Dermoscopy after a 4-week course of a topicalsteroid (b) shows improvement of inflammation bydisplaying disappearance of the aforementioned vessels,

though orange areas (arrows) are now evident (however,they are not a typical sign of disease activity as theycorrespond to dermal haemosiderin deposits on histology)


Morphea and Extra-Genital Lichen SclerosusDermoscopy has been speculated to be a possi-ble effective technique for treatment monitor-ing of such conditions since it allows a moreaccurate assessment of inflammation regressionand fibrotic process compared to clinicalexamination only [40, 41]. Indeed, dermoscopyshows a better correlation with pathologicfindings, with erythema/vessels and white areas(ill-defined dull white globules in morphea andbright white areas in extra-genital lichen scle-rosus) strictly related to dermal inflammationand sclerosis, respectively [41]. Consequently, itis possible to optimize the duration of therapyaccording to the persistence/resolution of sub-clinical inflammatory signs despite an ‘‘appar-ent’’ clinical healing, thus preventing fibrosisprogression [41].

Pigmentary Dermatoses

VitiligoMilky/bright white structureless areas withsharp and convex margins represent the mostcommon dermoscopic pattern of vitiligo[42, 43]; other possible findings include whitehairs (leukotrichia), perifollicular pigmentation(more common in early and repigmentinglesions), perifollicular depigmentation, mar-ginal pigmentation, marginal reticular pig-mentation, reversed pigmentary network, andintralesional pigmentary (structureless or

network-like) patches, with the last two featuresbeing more common in early stages of disease[42, 43].

Of note, margins may sometimes also beirregular and/or less defined giving rise tospecific patterns (i.e. trichrome, ‘‘starburst’’ and‘‘comet tail’’), which have been related to dis-ease activity [42, 43]. Additional signs of active/progressive lesions include the presence of smallwhite globules in perilesional skin (described assatellites, confetti-like pattern and ‘‘tapiocasago’’ appearance) and micro-Koebner’s phe-nomenon (i.e. occurrence of isomorphic depig-mented streaks along the line of trauma aroundthe main vitiligo patch) [42, 43]. On the otherhand, sharp borders and perilesional hyperpig-mentation are considered signs of disease sta-bility [42, 43]. From a management point ofview, it is important to known if a vitiligo lesionis in a stable or active phase as some therapiesare strictly related to disease stage (e.g. surgicaltreatments are preferentially done when diseaseis stable) [42, 43].

Additionally, dermoscopy has been reportedto be a reliable tool to assess initial therapeuticresponse to treatments as it may show increasesin perilesional and intralesional pigmentationthat are not visible to the naked eye [44, 45].

Finally, dermoscopic examination has alsobeen shown to be useful to predict therapeuticoutcomes [46–48]. In particular, a recent studyshowed a reduced response rate to excimer lasertherapy of non-segmental vitiligous lesions

Fig. 9 Dermoscopy of a mature/well-developed mastocytoma reveals yellowish areas (a), while a diffuse light-browndiscoloration is seen in a healing lesion (b)


displaying white hairs on baseline dermoscopy[46]. That finding was confirmed in a study onpatients suffering from segmental vitiligo trea-ted with either medical (phototherapy or lasertherapy) or surgical treatments [47], yet it wasnot seen in another study investigating patientswith non-segmental vitiligo treated with ultra-violet B phototherapy, which only found acorrelation between positive response and der-moscopic evidence of perifollicular pigmenta-tion at baseline (Fig. 10) [48].

MelasmaDermoscopic features of melasma includelight/dark brown, grey or blue pseudonetwork(pigmentation with follicular and appendagesostia sparing) and, less commonly, telangiec-tasias (which are usually less thick than steroidoveruse-induced vessels) as well as pigmentedannular or arcuate structures, dots and globules[49–54].

The role of dermoscopy in therapeuticmanagement of melasma has been investigatedby several studies including patients treated

Fig. 10 Baseline clinical image of vitiligo involving rightarmpit (inset: dermoscopic examination shows presence ofsubclinical perifollicular pigmentation) (a); the samelesions seen by using a computer-aided method (b).Significant improvement at the end of the 30 sessions ofnarrowband ultraviolet B phototherapy is visible on

clinical examination (c) and by using a computer-aidedmethod (d). (From Errichetti E, et al. Dermatol Ther(Heidelb) 2020. https://doi.org/10.1007/s13555-020-00431-6)


https://doi.org/10.1007/s13555-020-00431-6

https://doi.org/10.1007/s13555-020-00431-6

with either topical treatments (tranexamic acid,hydroquinone, and combinations of hydro-quinone, glycolic acid and hyaluronic acid) orlaser therapies [49–54]. Besides the use of thistechnique in following up lesions changes dur-ing the treatment to see the attenuation/re-gression of pigmentary and vascular structures,dermoscopic examination also has a role inpredicting therapeutic response in melasma as itallow one to establish the deepness of thelesions, i.e. epidermal (dark to light brown col-our and sharp edges), dermal (grey to blue col-our with ill-defined margins with or withoutannular/arcuate pigmented structures) or mixed(combination of dermoscopic findings), withthe last two variants being notoriously moreresistant to therapies [49–54].

Additionally, dermoscopy is useful inchoosing the type of treatment since the pres-ence of a significant vascular component ondermoscopic assessment (‘‘telangiectatic mel-asma’’) would support the use of a laser therapytargeting vessels (e.g. pulsed-dye laser) [54].

Infectious Dermatoses

ScabiesScabies is one of the skin diseases that benefitmost from dermoscopy in terms of both diag-nosis and treatment monitoring [55, 56]. Hand-helddermoscopic examination typicallydisplaysthe pathognomonic ‘‘delta-wing jet with con-trail’’ sign, which represents the irregular burrowexcavated by themite, whose anterior part of thebody is visible as a small black arrowhead/trian-gular area at the end of the whitish wavy line(corresponding to the burrow) [3–7]. At highermagnification (videodermoscopy—920 to9600), epimeres (chitinous internal structuresattached to legs), anterior outlines, eating toolsand both pairs of forelegs and hind legs of Sar-coptes scabiei are visible [55, 56].

Post-treatment follow-up of scabies mayallow one to see the absence of migration ofmites (after 24 h) and their progressive degra-dation with a gradual disappearance of theiroutlines and replacement with an amorphousmaterial [55]. These last morphological changeshave been reported to occur after mite

immobilization, i.e. 48 h [55] to 2 weeks [56]after therapy administration. Notably, evenhand-held dermoscopes (910 magnification)may show the disappearance of the ‘‘arrow-head/triangular area’’, although the accuracy oflow magnification is obviously lesser thanvideodermoscopic evaluation [57].

PediculosisDermoscopic examination of pediculosis mayeasily allow identification of parasites and eggswhen these are not easy to identify by clinicalinspection [57, 58]. Morphology of head andbody lice is similar (though the latter is bigger)and consists of an elongated body, three pairs ofclawed legs and narrow anterior mouthparts,while pubic lice differ from the presence of ashort broad body [57, 58] (Fig. 11).

Additionally, besides demonstrating theabsence of parasites after an appropriate ther-apy, dermoscopy may also help assess the pres-ence of viable nits [57, 58]. Specifically, nitscontaining nymphs are ovoid brown structures,while empty nits are translucent and typicallyshow a plane and fissured free ending[57, 58] (Fig. 11).

DemodicosisUnder dermoscopy, demodicosis typicallyshows white-yellow follicular plugs which may

Fig. 11 Dermoscopy of a case of pediculosis pubis shows alouse (arrowhead) as well as a viable nit having a browncolour and oval shape (arrow) (a); empty nits (arrows) in apatient successfully treated for pediculosis capitis are seenas translucent structures showing a plane free ending (b)


or not protrude from the skin surface (known as‘‘Demodex tails’’ and ‘‘Demodex follicular open-ings’’, respectively) [3–5]. Other unspecific der-moscopic findings may be observed, includingdiffuse erythema, scaling, pustules and reticulardilated vessels [3–5].

It has been speculated that dermoscopy mayhave a role in monitoring and optimizingtreatment of this condition by showing thereduction of subclinical follicular plugs as theywould be strictly related to the presence of amixture of keratotic material and mites in thefollicles [59].

WartsCommon and plantar warts are classically typi-fied by dermatoglyphic/skin furrows interrup-tion, dotted and/or linear vessels having whitehalos, finger-like projections containing elon-gated vessels surrounded by a white halo andthrombosed capillaries (seen as purple-blackdots/lines), while plane warts usually featuredermatoglyphic/skin furrows interruptionalong with dotted vessels over a white back-ground [5–7].

The main application of dermoscopy intherapeutic management of such lesions isrepresented by the assessment of a completehealing as it allows one to see subclinical per-sistence of infection (Fig. 12) that may be

responsible for its spreading if not further trea-ted [60].

CONCLUSIONS

Dermoscopy may benefit therapeutic manage-ment of several non-tumoral skin conditions byhighlighting possible clinically subtle/invisibleresponse predictor factors (positive or negative)and monitoring the lesions changes at a sub-clinical level. The first possibility may help inchoosing the most appropriate therapy andavoid unnecessary treatments, while the secondadvantage may allow one to appreciate earlysigns of response/recurrence (before clinicalchanges become evident) as well as ensure thedisappearance of subclinical findings that maybe related to inflammation/infection persis-tence, thus preventing disease spreading/recurrence.

Importantly, available supporting evidencehas sometimes been drawn by using specifictreatments or according to single case reports/mechanism-based reasoning. Therefore, futurestudies including dermoscopic-pathologicalcorrelation of subclinical changes during andafter therapies are needed to support the exist-ing promising data.

ACKNOWLEDGEMENTS

Funding. No funding or sponsorship wasreceived for this study or publication of thisarticle.

Authorship. The named author meets theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thisarticle, takes responsibility for the integrity ofthe work as a whole, and has given theirapproval for this version to be published.

Authorship Contributions. All writers andcontributors who participated in the prepara-tion of the manuscript are listed as authors.

Fig. 12 Plantar wart. Despite clinical examination indi-cating healing (a), dermoscopic examination still displayslesion remnant by revealing dermatoglyphics interruption(arrow) (b)


Disclosures. Enzo Errichetti is a member ofthe journal’s Editorial Board.

Compliance with Ethics Guidelines. Thisarticle is based on previously conducted studiesand does not contain any studies with humanparticipants or animals performed by theauthor.

Data Availability. Data sharing is notapplicable to this article as no datasets weregenerated or analyzed during the current study.

Open Access. This article is licensed under aCreative Commons Attribution-NonCommer-cial 4.0 International License, which permitsany non-commercial use, sharing, adaptation,distribution and reproduction in any mediumor format, as long as you give appropriate creditto the original author(s) and the source, providea link to the Creative Commons licence, andindicate if changes were made. The images orother third party material in this article areincluded in the article’s Creative Commonslicence, unless indicated otherwise in a creditline to the material. If material is not includedin the article’s Creative Commons licence andyour intended use is not permitted by statutoryregulation or exceeds the permitted use, youwill need to obtain permission directly from thecopyright holder. To view a copy of this licence,visit http://creativecommons.org/licenses/by-nc/4.0/.

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