Dermoscopy in dermatological practice has a long history. It was carried out for the first time by Kolhause in 1663, for evaluating blood vessels of the nail bed. Nowadays there are two types of dermoscopy: polarized – for deeply located structures in the skin, and non-polarized – which visualizes the surface layers of the skin.
Initially, dermoscopic examination was used for diagnosing benign and malignant skin lesions, but now it is also used to detect other skin diseases. The positive aspects of dermoscopy include: non-invasiveness, easy to use, time-saving, less financial resources necessary and an improved system of saving documentation, which is convenient when using a stationary digital dermoscope.
Clinical and dermoscopic picture of connective tissue diseases
In addition to the use of dermoscopy in dermato-oncology, this method is also used in general dermatology [1]. Over time, such specific terms appeared as trichoscopy (dermoscopy of the scalp), onychoscopy (nail dermoscopy), entomodermoscopy (dermoscopy of infectious and parasitic skin diseases), inflammoscopy (dermatoscopy of inflammatory skin diseases). Dermoscopic characteristics of chronic inflammatory skin diseases, including the dermoscopic picture characteristic for connective tissue diseases, turned out to be especially informative [2, 3]. In cases of skin inflammatory diseases, dermoscopic examination helps to avoid the use of minimally invasive or invasive methods in order to establish a diagnosis [4]. Dermoscopic examination is informative not only for differential diagnosis, but also for prognostic assessment and monitoring of diseases [5]. Dermoscopic examination has been successfully used in diagnosing connective tissue diseases such as discoid lupus erythematosus, dermatomyositis and localized scleroderma.
Dermoscopy of discoid lupus erythematosus
Autoimmune and inflammatory diseases of the skin are characterized by generalized inflammation caused by the immune system activation, particularly acquired immune type activation. The main role is attributed to genetic factors. Discoid lupus erythematosus is a chronic type of cutaneous lupus erythematosus, mediated by autoimmune processes. Provoking factors include genetic predisposition, toxins and exposure to sunlight [6]. Clinically DLE is characterized by scaly, round-oval shaped well demarcated skin lesions. The rashes are mostly localized on the areas of exposure to sunlight (face, scalp, ears, upper limbs) and this condition often leads to cicatricial hair loss. It is important that the mucous membranes of the eyes, mouth and vagina can also be affected. The acute phase of the disease is characterized by the presence of signs of an inflammatory process (i.e. redness, desquamation), later followed by cicatrix, appendages atrophy or color changes of the skin [7–9]. When discoid lupus erythematosus is localized on the scalp, a hyperemic rash is expressed on the surface of the head. Later, hair loss and cicatricial changes of the skin are noticeable, depigmentation and smooth surface with dilated blood vessels. When it is localized on the lips, hyperkeratosis and red or gray color of the mucous membrane of the lips is expressed. Eye-lid damage, such as blepharitis, is less common [10]. Diagnosis of lupus erythematosus is quite complicated and requires differential diagnosis for example with actinic keratosis, seborrheic dermatitis, psoriasis, lichen planus, sarcoidosis, among others. Recently, dermoscopy has been widely used as a diagnostic, non-invasive and easy to handle method. The dermoscopic presentation of discoid lupus erythematosus varies depending on the location of the skin lesion. But according to some studies, several common features have been identified: a perifollicular whitish rim, follicular keratin plugs, and an expanded network of blood vessels – telangiectasia [11]. According to some authors, discoid lupus erythematosus on the scalp is characterized by the following main dermoscopic signs: structureless areas, branched (arborizing) blood vessels, white scales, follicular keratin plugs, absence of follicular openings, perifollicular scaling, pinkish-white background, brown pigment inclusions and whitish fibrous areas. When the skin is injured by destructive lichenoid infiltrate, mainly follicular keratin plugs and a perifollicular white rim, brown pigmentation and structureless white areas are found [12]. In addition to the above-described dermoscopic picture, isolated cases have been identified when a whitish-bluish veil was found during dermoscopic examination of the scalp, among dark-skinned patients, which histologically corresponded to the absence of pigment and the location of melanophages in the papillary dermis [13]. Follicular red dots were also found in several patients, which appeared as a regularly distributed polycyclic structure in the openings of the follicle, histologically corresponding to keratin plugs limited by blood vessels and erythrocyte extravasates [14]. As a rapid and non-invasive method, dermoscopic examination is important to make the diagnosis of cicatricial vs. non-cicatritial cause of alopecia [15]. Dermoscopic examination is also important for diagnosing autoimmune diseases of connective tissue because they can be associated with cicatricial changes, diffuse and telogen hair loss, alopecia areata, trichomegaly [16, 17]. Systemic lupus erythematosus is characterized by telogen hair loss, while the discoid form is characterized by scarring alopecia [18, 19]. Because non-scarring alopecia develops in systemic lupus erythematosus, it is often erroneously classified as alopecia areata, although there is a pronounced dermoscopic difference between these two. In alopecia areata dermoscopically there is a hair shaft like an exclamation mark, black and yellow dots and broken hair shafts. Systemic lupus erythematosus is characterized by thinning of the hair shaft, expansion of circulatory networks and perifollicular red dots. When discoid lupus erythematosus is on the face, differential diagnosis should be made between seborrheic dermatitis, acne rosacea, cutaneous tuberculosis, and sarcoidosis. It is difficult to find the difference between them, but in discoid lupus erythematosus, changes in the hair follicle and an expanded network of blood vessels dominate, while in cases of other diseases described above, yellowish scales, polygonal and pinpoint blood vessels and an orange background are found [20]. Dermoscopic examination is also a valuable tool in those rare cases when mucous membranes of the mouth and lips are affected by discoid lupus erythematosus. Differential diagnosis is carried out with actinic cheilitis and lichenoid changes [21–23]. In discoid lupus erythematosus, fibrous lesions are found in the form of whitish structureless areas, an expanded network of blood vessels and ulcerative lesions. When lips are involved, brown pigmented spots, desquamation, erosions and also hemorrhages are encountered [24].
Dermoscopy of dermatomyositis. Dermatomyositis is an inflammatory autoimmune disease affecting the skin and muscles. The etiology of taffecting has not been fully discovered. Trigger factors include: genetic predisposition, viral infections, solar radiation, medications and smoking.
Muscle weakness manifests itself gradually – it is difficult for patients to perform certain movements. Muscle weakness is often preceded by a skin rash that appears as purple-red patches and papules and is mainly located on the face, around the eyes, and over the upper chest and back, rarely on the lower and upper extremities. The disease is characterized by the presence of “Gottron’s papules”, which are mainly located over the joints of the fingers, and also may be on the elbow and knee. The skin changes are often painful, bleeding, and aggravated by exposure to the sunlight. Complications of the disease include weight loss and nutrient deficiencies caused by difficulties in swallowing, aspiration pneumonia, breathing problems, and calcium deposits located in muscles and in connective tissue.
Five main criteria are used to make a diagnosis of dermatomyositis, and blood test, muscle biopsy, an electrocardiogram are utilized. If there is a telangiectatic skin lesion, dermoscopy is also a rapid and helpuf diagnostic method. If dermatomyositis is suspected, several methods of dermoscopy are used: eponychial dermoscopy (capillaroscopy), scalp dermoscopy (trichoscopy), and video dermoscopy [25].
Eponychial dermoscopy (capillaroscopy) is a relatively new method that reflects microcirculation disorders not only in dermatomyositis, but also in Raynaud’s phenomenon, systemic sclerosis, and mixed connective tissue disease [26–29]. Dermatomyositis capillaroscopy reveals the following dermoscopic features: elongated capillaries, avascular (without blood vessels) areas, capillary disorganization, twisted blood vessels, dilated capillaries, and hemorrhages. Some studies show that with the progression of the disease in patients with dermatomyositis, the density of eponychial capillaries and their number decrease, which determines the prognosis of the disease [30]. A correlation between a decrease in capillary density and involvement of the lungs was also revealed; such correlation was not detected in cardiac injury [31, 32]. With regard to skin manifestations, a nonspecific distribution of polymorphic blood vessels and whitish-pinkish structureless areas were noted at the sites of Gottron’s papules [33, 34].
Dermoscopic examination is informative not only for individual skin lesions, but also for diagnosing erythroderma, since dermatomyositis can also cause this sign similarly to other diseases [35, 36]. In case of dermatomyositis with lesions of the scalp, general characteristic signs of inflammatory skin diseases will also be clinically identified. In such cases, differential diagnosis should be carried out with diseases such as psoriasis, seborrheic dermatitis, lichen planus, discoid lupus erythematosus and contact dermatitis. Dermatomyositis is characterized by a specific network of blood vessels and structureless areas [37]. With dermoscopic examination, it is possible to distinguish a rash of the scalp caused by dermatomyositis, systemic lupus erythematosus or systemic sclerosis from each other. Microaneurysm blood vessels are found in dermatomyositis, while polymorphic vessels are found in systemic sclerosis and systemic lupus erythematosus. Although in all 3 cases, common signs were expressed: perifollicular brown-reddish pigmentation, decreased diameter of the hair shaft and whitish areas [38]. Trichoscopic manifestations of dermatomyositis are: branched and linear blood vessels, perifollicular pigmentation, erythema and scaling, white or yellowish scales that are located in the spaces between the follicles and whitish-pink areas. According to some authors, trichoscopic changes in dermatomyositis coincide with dermoscopic signs detected during capillaroscopy, and especially with morphological changes in blood vessels [39]. Term scleroderma refers to group of diseases characterized by hardening of the skin, muscles, blood vessels, and internal organs. The etiology is not clear and risk factors include: genetic predisposition, viral infections, medications, exposure to chemicals, and immune system disregulation. It often occurs with other systemic symptoms. There are two main forms of scleroderma: systemic and localized (morphea). Systemic scleroderma involves the limbs, lungs, kidneys, heart, teeth, digestive system and joints. Common symptoms include fibrosis of the skin, cold sensitivity of the hands and feet and general weakness.
Dermoscopy of morphea. Localized scleroderma (morphea) is a disease that presents only skin lesions and is not characterized by signs of systemic organ involvement. The manifestation of morphea depends on the stage and phase of the disease. During the acute phase, it is characterized by reddish-purple spots, which are often localized on the abdomen, chest and back. Later, whitish depigmentation and skin sclerosis develop in the central part of the patches. With a linear form of morphea, the lesions are localized along the limbs, on the scalp and on the forehead. Over time, the skin becomes atrophic, smooth and shiny. In systemic scleroderma, capillaroscopy is helpful, as well as in other cases with Raynaud's phenomenon [40, 41]. Some authors believe that in systemic sclerosis, capillaroscopy is equally informative when using a polarized and non-polarized dermatoscope with different degrees of image magnification [42, 43]. Dermoscopy distinguishes scleroderma from pseudoscleroderma, which are clinically similar. In scleroderma, along with other diagnostic tests, dermoscopy is used as an identifying tool for detecting skin sclerosis [44]. Capillaroscopy can determine the phase of the course of the systemic process, in particular, early stages are characterized by dilatation of capillaries and hemorrhages, the active phase of the disease is characterized by a more pronounced network of capillaries, and late changes include a decrease in size and number of capillaries and avascular areas increase [45, 46]. Some authors believe that dilated blood vessels and bleeding around the nails are hallmarks of systemic sclerosis [47, 48]. Scientific articles about these precursors were written long time ago [49, 50].
Among non-invasive methods, dermoscopy is used very often for morphea diagnosis. Polarized luminescence shows “fibrous rays”, linear blood vessels that cross the fibrous areas perpendicularly and the absence of hair shafts compared to healthy skin [51]. With the help of dermoscopic examination, it is possible to make differentiation between morphea and lichen sclerosus, which is also characterized by atrophic and fibrous changes of the skin. Dermoscopically in lichen sclerosus, whitish-yellowish spots and follicular keratin plugs of the same color are expressed [52–54].
Linear morphea localized on the scalp is characterized by atrophic, linear areas, hair loss, atrophy of the hair follicles, white areas, black dots, broken hair shafts, short, thick, linear and branched blood vessels on the periphery of the lesion [55, 56].
And in the end, as a conclusion, based on numerous literary sources, we can say that dermoscopic examination has a great value and is very helpful tool in detecting and differentiating conditions from connective tissue diseases in order to properly approach them as presented in table 1.
Funding
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Ethical approval
Not applicable.
Conflict of interest
The authors declare no conflict of interest.
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