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Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 48-51

Clinical and Dermoscopic Spectrum: Novel Findings in Interesting Cases

Department of Dermatology, Rajiv Gandhi Medical College and CSM Hospital, Thane Municipal Corporation, Thane, Maharashtra, India

Date of Submission30-Dec-2018
Date of Decision26-Apr-2020
Date of Acceptance11-Jun-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Sneharani Hariprasad Chandak
Chandak, 86A/14, Vrindavan Society, Thane - 400 601, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_155_18

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Uncommon, interesting clinical entities presenting in dermatological practice often challenges the diagnostic skills of a trained dermatologist. A non-invasive tool for recognition of these conditions is especially relevant in the paediatric population and dermoscopy plays a pivotal role in diagnosing these cases. A spectrum of novel clinical and dermoscopic findings is reported in four interesting cases. (vitiligo ponctue, cutaneous larva migrans, zosteriform angiokeratoma, linear milia en plaque).

Keywords: Angiokeratoma, larva migrans, milia, vitiligo ponctue

How to cite this article:
Chandak SH, Viswanath V. Clinical and Dermoscopic Spectrum: Novel Findings in Interesting Cases. Indian J Paediatr Dermatol 2021;22:48-51

How to cite this URL:
Chandak SH, Viswanath V. Clinical and Dermoscopic Spectrum: Novel Findings in Interesting Cases. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Apr 20];22:48-51. Available from: https://www.ijpd.in/text.asp?2021/22/1/48/305803

  Introduction Top

Uncommon, interesting clinical entities often pose a diagnostic challenge; dermoscopy is a valuable, noninvasive tool in diagnosing these cases. Specific and nonspecific dermoscopic findings and criteria for various diseases have been described, but these should always be interpreted in relevance to the clinical context. We report four interesting clinical entities with a spectrum of novel clinical and dermoscopic findings.

  Case Reports Top

Clinical and dermoscopic evaluation of four interesting pediatric cases is described. Dermoscopy was done using Dermlite DL4. Other relevant investigations including biopsy, specific serological, and imaging studies were performed as per clinical diagnosis.

Case 1

A 12-year-old male child presented with multiple asymptomatic white spots over lips and acral areas (hands and feet) since 7 months. Lesions were progressively increasing in number but not in size. Cutaneous examination revealed multiple depigmented macular and few papular lesions (pinpoint) distributed over lips, hands, and feet [Figure 1]a and [Figure 1]b. Provisional diagnosis of vitiligo and lichen nitidus was considered. Dermoscopy over hands and feet showed perifollicular depigmentation and hyperpigmentation and minute hyperpigmentary spots [Figure 1]c. Dermoscopy over lips showed star burst pattern and comet tail sign and a diagnosis vitiligo ponctue was confirmed [Figure 1]d.
Figure 1: Vitiligo ponctue: Clinical (a and b): hands, lips: Pinpoint depigmented papules and macules; Dermoscopy (c and d): hands, lips: perifollicular depigmentation (blue arrow), perifollicular hyperpigmentation (red arrow) and minute hyperpigmentary spots (black arrow), star burst pattern (green arrow) and comet tail sign (red circle)

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Case 2

A 1-year-old female child presented with linear, reddish structures over trunk, lesions were migratory in nature and shifted from face to back within 8 days. Close contact with cats and dogs was elicited on detailed history. Cutaneous examination revealed elevated, erythematous, curvilinear track, and hyperpigmented linear lines [Figure 2]a. Provisional diagnosis of cutaneous larva migrans (CLM) was considered. Dermoscopy showed segmented brown thread-like structures suggestive of larval body [Figure 2]b. Linear pigmentation pattern and peripheral scaling were seen at areas of previous larval invasion [Figure 2]c. On investigations, leukocytosis (16,160 cells/cumm) was noted with an absolute eosinophil count of 1360 cells/cumm. Stool examination was normal. Initial response to topical ivermectin and oral albendazole was moderate, complete clearance was observed with oral ivermectin.
Figure 2: Cutaneous larva migrans: Clinical (a): active larval invasion (red arrow), old larval invasion (yellow arrow); Dermoscopy (b and c): active larval invasion showing segmented brown thread-like structure (green arrow); old larval invasion showing linear pigmentation pattern and peripheral scaling (blue arrow)

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Case 3

A 9-month-old female child presented with multiple, asymptomatic progressively increasing swellings over the left forearm since birth. There was no history of bleeding from lesions. Cutaneous examination revealed multiple hyperpigmented nodules of varying size in a dermatomal pattern, the largest being 2 cm × 2 cm × 3 cm, few areas showed crusting [Figure 3]a. There was no difference in limb girth between both upper extremities. A differential diagnosis of angiokeratoma and Klippel-Trenaunay syndrome (KTS) was considered. Dermoscopy showed dark lacunae, red lacunae, whitish veil, erythema, and hemorrhagic crust [Figure 3]b and [Figure 3]c. Ultrasonography of local area and Doppler showed multiple hypoechoic lesions in deep subcutaneous plane with internal vascularity, however, no connection between lesions was observed. A diagnosis of zosteriform angiokeratoma was made. Topical timolol maleate drops were advised with minimal improvement.
Figure 3: Angiokeratoma (zosteriform pattern): Clinical (a): hyperpigmented nodules of varying size in dermatomal pattern with crusting; Dermoscopy (b and c): dark lacunae (red arrow), red lacunae (yellow arrow), scaling (blue arrow), hemorrhagic crust (pink arrow), whitish veil (green arrow)

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Case 4

A 9-year-old male child presented with multiple, asymptomatic progressively increasing milky white elevated lesions over the right forearm since birth. There was no prior history of trauma or topical application. Cutaneous examination revealed multiple whitish papules grouped, forming a linear pattern (following Blaschko's lines) with central depression in few lesions [Figure 4]a. A differential diagnosis of linear milia en plaque, porokeratotic eccrine ostial, and dermal duct nevus was considered. Dermoscopy showed whitish structureless areas with yellowish white keratotic plugs in the center of papules suggestive of milia [Figure 4]b and [Figure 4]c. Needling of the lesions was done.
Figure 4: Linear milia en plaque: Clinical (a): multiple whitish grouped papules in linear pattern with central depression; Dermoscopy (b and c): whitish structureless areas with yellowish white keratotic plugs in the center of papules

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The histopathological findings correlated with dermoscopic findings in all cases except the biopsy from CLM patient (case 2) did not reveal any abnormality. The salient histological findings were the absence of melanocytes in basal layer in vitiligo ponctue [Figure 5]a, cystic structure in the dermis lined by stratified squamous epithelium and containing keratinous material in milia en plaque [Figure 5]b and epidermal hyperplasia with dilated, thin walled capillaries in the dermis in zosteriform angiokeratoma [Figure 5]c,[Figure 5]d.
Figure 5: Vitiligo ponctue; absence of basal melanocytes (40X) (b): Milia en plaque; cystic structure lined by stratified squamous epithelium containing keratinous material in dermis (10X) (c): Zosteriform angiokeratoma; epidermal hyperplasia with dilated vessels in dermis (10X) (d) Zosteriform angiokeratoma; dilated thin walled capillaries in dermis (40X)

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  Discussion Top

Dermoscopy is a useful tool for noninvasive diagnosis in pediatric population. A summary of the novel and unusual clinical and dermoscopic findings in the case series has shown in [Table 1].
Table 1: Summary of cases: Novel and unusual clinical and dermoscopic findings

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Vitiligo ponctue, a rare variant presents with discrete, confetti-like amelanotic macules occurring on normal or hyperpigmented skin.[1],[2] Till date, only three cases of vitiligo ponctue in adulthood have been reported. This is the first report of dermoscopic findings in vitiligo ponctue which simulate findings seen in classical vitiligo such as comet tail, star burst, perifollicular depigmentation, and hyperpigmentation.

Dermoscopic features of CLM reveal translucent brownish structureless areas in a segmental arrangement corresponding to body of larva, while red dotted vessels correspond to empty burrow.[3],[4] Segmented brown thread-like structures suggestive of body of larva was seen in this patient; however, novel findings of scaling and linear pigmentation were seen in old larval tract areas.

Angiokeratoma lesions in a zosteriform pattern with onset of lesions at birth and without findings of KTS are uncommon. Few cases of angiokeratoma in zosteriform patterns have been reported and most have manifested in adulthood. Only two cases of hyperkeratotic zosteriform angiokeratoma have been reported in children and these were associated with KTS.[5],[6] Angiokeratomas can mimic pigmented lesions (melanocytic nevi, Spitz nevi, malignant melanomas) and vascular lesions (angiomas, hemangiomas, and pyogenic granulomas). Dermoscopic findings in angiokeratomas are classical and help to differentiate from pigmentary and vascular mimickers.[7] The presence of well-demarcated, round, and dark lacunae which histologically represent dilated vessels with thrombosis is a strong diagnostic sign. Red lacunae correspond to dilated vascular spaces without thrombosis in the upper dermis, while a whitish veil corresponds to acanthosis or hyperkeratosis.[7]

Linear milia en plaque is a rare entity with few reported cases.[8],[9] Dermoscopic patterns include yellowish structureless areas, vascular patterns over milia, papule with homogenous blue pigmentation.[10] Whitish structureless areas with central keratotic plug is a novel dermoscopic finding.

  Conclusion Top

In clinical dermatology practice, interesting cases often challenge the diagnostic skills of a trained dermatologist. Dermoscopy plays a pivotal role in diagnosing these cases since it is an added armamentarium to the dermatologist for noninvasive recognition of cutaneous disorders; especially in the pediatric population.

Informed consent

Taken from parents as our patients were minor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patients' consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initial will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Arunprasath P, Reji S, Srivenkateswaran K. Vitiligo ponctue. Pigment Int 2015;2:103.  Back to cited text no. 1
  [Full text]  
Passeron T, Ortonne JP. Vitiligo and disorders of hypopigmentation. In: Bolognia JL, Schaffer JV, Cerroni L. editors. Dermatology. 4th ed. London: Elsevier; 2018. p. 1087-14.  Back to cited text no. 2
Zalaudek I, Giacomel J, Cabo H, Di Stefani A, Ferrara G, Hofmann-Wellenhof R, et al. Entodermoscopy: A new tool for diagnosing skin infections and infestations. Dermatology 2008;216:14-23.  Back to cited text no. 3
Crocker A, Sánchez L, Quiñones R, González R, Orendain N. Dermoscopic findings in larva migrans. Dermatol Rev Mex 2015;59:98-101.  Back to cited text no. 4
Wankhade V, Singh R, Sadhwani V, Kodate P, Disawal A. Angiokeratoma circumscriptum naeviforme with soft tissue hypertrophy and deep venous malformation: A variant of Klippel-Trenaunay syndrome? Indian Dermatol Online J 2014;5:S109-12.  Back to cited text no. 5
Das D, Patil P, Tambe SA, Nayak CS. Angiokeratoma circumscriptum in a child of Klippel-Trenaunay syndrome: A rare association. Indian J Paediatr Dermatol 2015;16:165-7.  Back to cited text no. 6
  [Full text]  
Zaballos P, Daufí C, Puig S, Argenziano G, Moreno-Ramírez D, Cabo H, et al. Dermoscopy of solitary angiokeratomas: A morphological study. Arch Dermatol 2007;143:318-25.  Back to cited text no. 7
Kautz O, Müller S, Braun-Falco M, Nashan D. Milia en plaque in a linear pattern. J Eur Acad Dermatol Venereol 2009;23:1335-6.  Back to cited text no. 8
Lee SH, Kim SC. Linear milia en plaque on the central face: An acquired skin rash following Blaschko's lines? J Dermatol 2012;39:936-7.  Back to cited text no. 9
Behera B, Mathews I, Vinupriya S, Chandrashekar L, Thappa DM, Srinivas BH. Milia: A dermoscopic pitfall. J Am Acad Dermatol 2017;77:e29-31.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


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