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Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 249-250

Dermatoscopic findings of pityriasis lichenoides et varioliformis acuta


Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Submission25-Nov-2019
Date of Decision24-Dec-2019
Date of Acceptance21-Feb-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Pragya Ashok Nair
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_115_19

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How to cite this article:
Bhut A, Shah A, Nair PA. Dermatoscopic findings of pityriasis lichenoides et varioliformis acuta. Indian J Paediatr Dermatol 2020;21:249-50

How to cite this URL:
Bhut A, Shah A, Nair PA. Dermatoscopic findings of pityriasis lichenoides et varioliformis acuta. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Aug 13];21:249-50. Available from: http://www.ijpd.in/text.asp?2020/21/3/249/288486



Sir,

An 11-year-old boy presented with multiple, generalized, polymorphous crusted papules and hypopigmented macules, with 2–3 vesicles present over the chest, abdomen, back [Figure 1]a, and bilateral upper and lower limbs [Figure 1]b, sparing the face, palms, soles, and scalp for 2 months with no history of itching except occasional burning. His personal and family history was insignificant. No history of any medications or episode of infection was elicited. No oral cavity involvement or nail changes were present. New lesions were seen in DE-300 Polarizing Digital Dermatoscope (Firefly) having ×20 magnification, which showed central crust, peripheral white scale, blue-gray areas, white structureless areas, linear vessels, and red dots [Figure 2]. Histopathology showed mild spongiosis, irregular acanthosis, and decreased granular layer with focal ulceration of the epidermis, lichenoid perivascular inflammatory infiltrate of lymphocytes, and plasma cells in the papillary dermis extending to the epidermis with vacuolar alteration of the basal layers [Figure 3]. The changes confirmed the diagnosis of pityriasis lichenoides et varioliformis acuta (PLEVA).
Figure 1: Multiple, generalized, polymorphous crusted papules and hypopigmented macules, with 2–3 vesicles present over (a) the back and (b) upper limbs

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Figure 2: Dermatoscopy with DE-300 Polarizing Digital Dermatoscope (Firefly) having ×20 magnification showing a central crust (black arrow), peripheral white scale (red arrow), blue-gray areas (white arrow),whitish-structureless areas (blue arrow), linear vessels (yellow arrow), and red dots (green arrow)

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Figure 3: Histopathology showing mild spongiosis, irregular acanthosis, and decreased granular layer with focal ulceration of epidermis, lichenoid perivascular inflammatory infiltrate (H and E, ×40)

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PLEVA, also known as Mucha–Habermann disease, is an uncommon cutaneous inflammatory disorder presenting as an acute eruption of inflammatory papules and vesicles that eventually develop hemorrhagic or necrotic crusts, most frequently affecting young adults and children.[1]

The etiology of PLEVA is unknown, but it has been postulated to be due to aberrant immune response to viral, bacterial, or protozoal infections; immune complex-mediated hypersensitivity; or an inflammatory response secondary to T-cell dyscrasia.[1]

Lesions of PLEVA are generally asymptomatic but can have itching or burning sensation. PLEVA usually begins as an acute eruption of multiple, erythematous macules that rapidly evolve to form 3–15 mm inflammatory papules and papulovesicles, which develop hemorrhagic or necrotic crusts. Individual lesions develop as crusts, ulcers, vesicles, or pustules and if dermal damage is extensive, then lesions may heal with varioliform scars.[2] Trunk, proximal extremities, and skin flexures are the most common sites for involvement, but any site can be affected. Mucosal involvement is typically absent. New lesions often develop as earlier lesions resolve, resulting in the simultaneous presence of lesions in various stages of development. Hypopigmentation and hyperpigmentation frequently persist once lesion resolves. PLEVA can mimic various skin conditions such as chicken pox, lymphomatoid papulosis, guttate psoriasis, lichen planus, and pityriasis rosea.[2]

The histopathology of PLEVA is not pathognomonic. Dermoscopy is considered the stethoscope for dermatologists as it is anin vivo method of diagnostic technique to visualize the skin structures not seen by the naked eye. Dermoscopic patterns in PLEVA include white-colored structureless areas, a central crust, red globules, blue-gray areas, yellow globules, and scaling.[3]

Ankad and Beergouder described dermoscopic patterns in early and late lesions of PLEVA. In early lesions, an amorphous brownish area around the hair follicles, within a rim of white scale and dotted vessels at the periphery, is noted, whereas white-colored, structureless areas and a central crust-plug surrounded by a rim of white scale, red dots, and hemorrhages are observed in late lesions.[3] An amorphous brownish structure corresponds to a central crust consisting of basophilic material in the epidermis and wedge-shaped lymphocytic infiltrate in the dermis. Red dots and hemorrhages represent microhemorrhages and extravasations of red blood cells in the papillary dermis and dilatation of blood vessels. Whitish-structureless areas with a central crust-plug are due to hyperkeratosis, acanthosis, and epidermal erosion. Vague glomerular vessels represent dilated vessels and scaling is as a result of hyperkeratosis. Our case showed changes of late phase of PLEVA with a central crust, a rim of white scale, hemorrhage, and red dots. The central crust and white structureless areas may be due to irregular acanthosis and focal ulceration of the epidermis. Spongiosis and lichenoid perivascular inflammatory infiltrate of lymphocytes and plasma cells in the papillary dermis extending to the epidermis with vacuolar alteration of basal layers lead to blue-gray areas. Although there were hemorrhage and red dots seen in dermoscopy, we could not find any vascular involvement in the histopathological section.

Vascular patterns vary from dots, to linear, to hemorrhages and are arranged either in a targetoid or dotted pattern. In a study of dermoscopy of PLEVA by Lacarrubba et al., the authors observed an amorphous brownish structure and a ring of pinpoint and linear vessels in a “targetoid” pattern surrounding whitish-structureless areas, which was also appreciated in our case.[4]

Ankad and Beergouder[5] described new findings that correlated with histopathological changes, including focal blue-gray areas and yellow globules, that represent melanin in the dermis, spongiosis, and basal cell degeneration. We also found blue-gray areas in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cozzio A, Hafner J, Kempf W, Häffner A, Palmedo G, Michaelis S, et al. Febrile ulceronecrotic Mucha-Habermann disease with clonality: A cutaneous T-cell lymphoma entity? J Am Acad Dermatol 2004;51:1014.  Back to cited text no. 1
    
2.
Perrin BS, Yan AC, Treat JR. Febrile ulceronecrotic Mucha-Habermann disease in a 34-month-old boy: A case report and review of the literature. Pediatr Dermatol 2012;29:53-8.  Back to cited text no. 2
    
3.
Ankad BS, Beergouder SL. Dermoscopy of inflammatory conditions: The journey so far. EMJ Dermatol 2017;5:98-105.  Back to cited text no. 3
    
4.
Lacarrubba F, Micali G. Dermoscopy of pityriasis lichenoides et varioliformis acuta. Arch Dermatol 2010;146:1322.  Back to cited text no. 4
    
5.
Ankad BS, Beergouder SL. Pityriasis lichenoides et varioliformis acuta in skin of color: New observations by dermoscopy. Dermatol Pract Concept 2017;7:27-34.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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