Abstract
Background:
The dermoscopic features of classic patch stage mycosis fungoides (MF) have been described, but data on plaque and tumoral stage as well as rarer MF subtypes is limited.
Objective:
To evaluate dermoscopic morphology and dermoscopic-pathological correlations of classic MF stages and investigate dermoscopic features of MF variants.
Methods:
Patients with histopathologically confirmed lesions of classic MF (patch, plaque and tumoral stage) or folliculotropic, erythrodermic and poikilodermatous MF were included. Standardized evaluation of dermoscopic pictures of the included MF variants and comparative analysis and dermoscopic-pathological correlation assessment of different stages of classic MF were performed.
Results:
A total of 118 instances were included (75 classic MF, 26 folliculotropic MF, 9 erythrodermic MF, and 8 poikilodermatous MF). Linear/linear-curved vessels and white scales in the skin furrows were significantly associated with patch-stage MF, while clustered dotted vessels were related to plaque-stage MF and peripheral linear vessels with branches, ulceration and red globules separated by white lines to tumor-stage MF. Moreover, patchy white scales were significantly more common in patches and plaques compared to tumors, whereas focal bright white structureless areas were related to plaque and tumoral stage. Vessels histopathologically corresponded to dilated vascular structures in the dermis, orange structureless areas to either dermal hemosiderin (patch/plaque stage) or dense cellular infiltration (tumors), bright white lines/structureless areas to dermal fibrosis, and ulceration to loss of epidermis. The main dermoscopic findings of folliculotropic MF were lack of hairs, dilated follicles and follicular plugs, while erythrodermic MF was mainly characterized by linear/dotted vessels, patchy white scales and focal orange structureless areas and poikilodermatous MF by focal white and brown structureless areas, white patchy scales and brown reticular lines.
Conclusion:
Dermoscopy may allow a more precise characterization of classic MF and reveal clues suggestive of the main MF variants.
Keywords: Dermoscopy, Folliculotropic mycosis fungoides, Infiltrative dermatoses, Lymphomas, Mycosis fungoides
INTRODUCTION
Mycosis fungoides (MF) is the most common type of primary cutaneous T-cell lymphoma, accounting for approximately 60% of all cases.1 Several clinical/pathological variants do exist, with classic MF (including patch, plaque and tumoral stages) being the most frequent subtype, followed by folliculotropic, poikilodermatous and erythrodermic MF.2–4 Rarer forms include syringotropic MF, granulomatous slack skin, pagetoid reticulosis, and MF presenting with unusual clinical manifestations (e.g., anetodermic patches, papules, purpuric patches, verrucous lesions, blisters/vesicles, pustules, ichthyosiform lesions, or hyper-/hypo-pigmented patches).2 Some variants, such as folliculotropic or syringotropic MF, are associated with worse prognosis, with consequent relevant management implications, as they require an early and more aggressive treatment.2,3 Similarly, in classic MF, plaque and tumoral stage are associated to a poorer long-term prognosis as compared to patch stage.2 Hence, a prompt recognition of MF subtypes and identification of disease stage in classic MF is of utmost importance in order to set a proper therapeutic management.2 However, diagnosis of some MF variants may be quite challenging on clinical ground and clinical classification of classic MF stages does not always reflect the histopathological background.2,4
Over the last few years, the dermoscopic features of classic patch stage MF have been described and dermoscopy was showed to facilitate its discrimination from clinically similar conditions.5,6 However, no comparative analysis among the various stages of classic MF has been performed and data on rarer MF subtypes are quite sparse.5 The aim of this study was to compare the dermoscopic morphology of different classic MF stages and investigate dermoscopic findings of the main MF variants, including folliculotropic, poikilodermatous and erythrodermic subtypes. The study was conducted in accordance with ethical guidelines and IRB approval was obtained.
MATERIALS AND METHODS
This was a retrospective observational study which was part of a larger project on primary cutaneous T-cell lymphomas launched by the International Dermoscopy Society (IDS) via an online call published on the IDS website (www.dermoscopy-ids.org).
Patients with MF (including classic, folliculotropic, poikilodermatous, and erythrodermic variants) diagnosed by histological and immunohistochemical analyses were eligible for the current study. Inclusion criteria for the study were a definite histopathological diagnosis and the availability of high quality clinical and dermoscopic images (captured at x10 magnification). Definition of MF subtypes and staging of classic MF lesions (patch, plaque and tumoral) was done according to clinical morphology and correlation with histopathological features in order to achieve a more precise classification.4 Patients having received treatment within 12 weeks before examination were excluded to avoid biases related to possible changes of dermoscopic patterns by therapies.
From each individual, the target lesion/area undergoing biopsy was included in the dermoscopic analysis. Patients’ age and gender, dermoscopy setting (polarized vs non-polarized light), and localization of the target lesion were recorded.
Two independent investigators (EE, AL), blinded for clinical and histopathological features, assessed the dermoscopic images by using predefined criteria. Interobserver agreement was evaluated through Cohen’s kappa coefficient. Dermoscopic variables were selected based on the consensus document by the IDS on dermoscopy of infiltrative, infectious and inflammatory dermatoses, that includes five standardized basic parameters with several possible sub-items for each of them:7 (I) vessels (morphology and distribution); (II) scales (color and distribution); (III) follicular findings; (IV) “other structures” (features other than vessels, scales and follicular findings) (including color and morphology); and (V) “specific clues” (features strongly suggestive of a dermatosis due to a strict correlation with highly specific/sensitive histological findings). In the latter category, we included 3 new variables, based on our preliminary observations: “red globules separated by white lines”, dilated follicles and lack of hairs. Dermoscopic-histopathological correlation of the main relevant dermoscopic findings was performed in cases in which a precise concordance between dermoscopic image and bioptic sampling area was available.
Statistical analysis
Absolute and relative frequencies were obtained for the dermoscopic characteristics within each clinical category of lesions. Non-parametric Pearson’s Chi Square test was used to flag differences among compared dermatoses within each category. The alpha level was set at 0.05. Statistical analyses were performed using IBM SPSS ver. 23 (Armonk, NY, USA).
RESULTS
A total of 118 lesions (56 trunk, 26 lower limbs, 20 upper limbs and 16 head/neck) from 118 patients (mean age: 60.1 years; 68 males and 50 females) were finally included in the analysis. Of them, 75 were classified as classic MF lesions (24 patches, 23 plaques, and 28 tumoral lesion), 26 as folliculotropic MF, 9 as erythrodermic MF, and 8 as poikilodermatous MF. Of 118 included dermoscopic images, 97 were acquired with dry polarized dermoscopy and 21 with non-polarized dermoscopy with immersion fluid.
The analytical results for classic MF are displayed in table 1 and examples are shown in Figures 1 and 2. The main dermoscopic findings (frequency ≥ 50%) of patch-stage MF were linear (75.0%), dotted (58.3%) and linear-curved (54.2%) vessels (mainly with an unspecific distribution) along with patchy white scales (62.5%) and orange structureless areas (50%; focal 45.8% and diffuse 4.2%). Plaque stage MF was mainly characterized by patchy white scales (78.3%), dotted vessels (82.6%) (mainly with an unspecific arrangement) and focal bright white structureless areas (60.9%), while the most common findings of tumoral stage MF were white scales (71.4%) and focal bright white (57.1%) and orange (50.0%) structureless areas. The interobserver agreement for dermoscopic variables was high with Cohen’s kappa ranging from 0.71 to 0.89.
Table 1.
Dermoscopic findings of patch, plaque and tumoral stage of mycosis fungoides (MF) with statistically significant differences among the three groups.
| Dermoscopic variable | Patch-type MF (n= 24) N (%) | Plaque-type MF (n=23) N (%) | Tumoral MF (n=28) N (%) | p-value |
|---|---|---|---|---|
| 1. Vessels | ||||
| Dotted vessels | 14 (58.3) | 19 (82.6) | 17 (60.7) | 0.859 |
| Uniform | 4 (16.7) | 5 (21.7) | 6 (21.4) | 0.733 |
| Clustered | 0 (0.0) | 3 (13.0) * | 0 (0.0) | 0.029 |
| Peripheral | 0 (0.0) | 0 (0.0) | 3 (10.7) | 0.073 |
| Unspecific | 10 (41.7) | 11 (47.8) | 8 (28.6) | 0.226 |
| Linear vessels | 18 (75.0) ** | 8 (34.8) | 11 (39.3) | 0.009 |
| Peripheral | 0 (0.0) | 0 (0.0) | 3 (10.7) | 0.073 |
| Reticular | 3 (12.5) * | 0 (0.0) | 0 (0.0) | 0.036 |
| Unspecific | 15 (62.5) * | 8 (34.8) | 8 (28.6) | 0.035 |
| Linear vessels with branches | 0 (0.0) | 0 (0.0) | 8 (28.6) ** | 0.001 |
| Uniform | 0 (0.0) | 0 (0.0) | 1 (3.6) | 0.427 |
| Peripheral | 0 (0.0) | 0 (0.0) | 4 (14.3) * | 0.029 |
| Unspecific | 0 (0.0) | 0 (0.0) | 3 (10.7) | 0.073 |
| Linear curved vessels | 13 (54.2) * | 1 (4.3) | 13 (46.4) * | 0.013 |
| Uniform | 1 (4.2) | 0 (0.0) | 2 (7.1) | 0.432 |
| Peripheral | 0 (0.0) | 0 (0.0) | 3 (10.7) | 0.073 |
| Unspecific | 12 (50.0) ** | 1 (4.3) | 8 (28.6) | 0.002 |
| 2. Scales | ||||
| White scales | 20 (83.3) | 21 (91.3) | 20 (71.4) | 0.185 |
| Diffuse WS | 0 (0.0) | 2 (8.7) | 3 (10.7) | 0.272 |
| Central WS | 0 (0.0) | 0 (0.0) | 2 (7.1) | 0.178 |
| Peripheral WS | 0 (0.0) | 1 (4.3) | 4 (14.3) | 0.104 |
| Patchy WS | 15 (62.5) * | 18 (78.3) * | 11 (39.3) | 0.017 |
| WS in the skin furrows | 5 (20.8) ** | 0 (0.0) | 0 (0.0) | 0.003 |
| Yellow scales/crusts | 1 (4.2) | 5 (21.7) | 3 (10.7) | 0.173 |
| Peripheral YSC | 0 (0.0) | 0 (0.0) | 1 (3.6) | 0.427 |
| Patchy YSC | 1 (4.2) | 5 (21.7) | 2 (7.1) | 0.111 |
| 3. Follicular findings | ||||
| Follicular plugs | 0 (0.0) | 1 (4.3) | 2 (7.1) | 0.422 |
| 4. Other structures | ||||
| Structureless areas (SA) | ||||
| White (bright) SA (focal) | 5 (20.8) | 14 (60.9) ** | 16 (57.1) ** | 0.009 |
| Brown SA (focal) | 0 (0.0) | 1 (4.3) | 0 (0.0) | 0.318 |
| Grey SA (focal) | 0 (0.0) | 0 (0.0) | 1 (3.6) | 0.427 |
| Orange SA (focal) | 11 (45.8) | 7 (30.4) | 14 (50.0) | 0.346 |
| Orange SA (diffuse) | 1 (4.2) | 3 (13.0) | 3 (10.7) | 0.550 |
| Purple SA (focal) | 0 (0.0) | 0 (0.0) | 1 (3.6) | 0.427 |
| Dots/Globules (D/G) | ||||
| White D | 0 (0.0) | 1 (4.3) | 4 (14.3) | 0.104 |
| White G | 0 (0.0) | 1 (4.3) | 2 (7.1) | 0.422 |
| Orange G | 0 (0.0) | 0 (0.0) | 2 (7.1) | 0.178 |
| Purple D | 3 (12.5) | 3 (13.0) | 1 (3.6) | 0.415 |
| Purple G | 0 (0.0) | 1 (4.3) | 2 (7.1) | 0.422 |
| Lines (L) | ||||
| White (bright) L (parallel) | 0 (0.0) | 1 (4.3) | 1 (3.6) | 0.608 |
| White (bright) L (reticular) | 0 (0.0) | 1 (4.3) | 2 (7.1) | 0.422 |
| White (bright) L (perpendicular) | 0 (0.0) | 1 (4.3) | 1 (3.6) | 0.608 |
| White (bright) L (unspecifically arranged) | 1 (4.2) | 3 (13.0) | 3 (10.7) | 0.550 |
| Brown L (unspecifically arranged) | 0 (0.0) | 1 (4.3) | 0 (0.0) | 0.318 |
| Circles (C) | ||||
| White C | 0 (0.0) | 2 (8.7) | 5 (17.9) | 0.087 |
| 5. Specific clues | ||||
| Ulceration | 0 (0.0) | 0 (0.0) | 6 (21.4) ** | 0.004 |
| Red globules separated by white lines | 0 (0.0) | 0 (0.0) | 4 (14.3) * | 0.029 |
p<0.05
p<0.01
Figure 1.
Classic mycosis fungoides. Patch stage: clinical (a), dermoscopic (b) and histological (c) appearance; dermoscopy mainly reveals linear/linear curved vessels, histologically corresponding to dilated vessels in papillary dermis (arrowheads), and orange structureless areas, related to hemosiderin deposits in the dermis (better seen in the inset) on histology (arrows). Plaque stage: clinical (d), dermoscopic (e) and histological (f) appearance; dermoscopic examination shows unspecifically distributed dotted and linear vessels, histologically corresponding to dilated vessels in papillary dermis (arrows), along with focal bright white areas histologically resulting from dermal fibrosis (stars). Tumoral stage: clinical (g), dermoscopic (h) and histological (i) appearance; dermoscopy displays orange structureless areas, bright white lines/areas, linear vessels with branches and ulceration histologically related to dense lymphomatous cellular infiltrate in the dermis, dermal fibrosis, arborizing dilated dermal vessels (arrows) and loss of epidermis (arrowheads), respectively.
Figure 2.
Examples of classic mycosis fungoides [plaque type (a) and flat tumoral type (c,e)] in which morphological staging may be difficult on clinical ground. Dermoscopy (b,d,f) shows clues typical of more advanced stages, i.e., bright white areas in plaque (arrow) (b) and flat tumor (arrow) (f) as well as red globules separated by white lines (d) and linear vessels with branches (arrowhead) (f) in flat tumors.
In the comparative analysis among the three stages of classic MF, we found linear vessels (p=0.009) (both reticular and unspecific arrangement), linear-curved vessels (unspecific distribution) (p=0.013), and white scales in the skin furrows (p=0.003) to be significantly associated with patch-stage compared to plaque and tumoral stage (Table 1, Figures 1 and 2). Conversely, clustered dotted vessels were the only finding specifically related to plaque-stage MF (p=0.029), whereas tumoral MF was associated with peripheral linear vessels with branches (p=0.001), ulceration (p=0.004) and red globules separated by white lines (p=0.029). Finally, patchy white scales were significantly more common in patches and plaques compared to tumors (p=0.017), while focal bright white structureless areas were related to both plaque and tumoral stage (p=0.009).
Regarding the other MF subtypes (Figure 3 – Table 2), the most frequent features of folliculotropic MF were lack of hairs (92.3%), dilated follicles (80.8%) and follicular plugs (61.5%), whereas erythrodermic MF was mainly typified by linear/dotted vessels (77.8% for both), patchy white scales (66.7%) and focal orange structureless areas (66.7%). Finally, focal white (87.5%) and brown (50.0%) structureless areas (configuring a “checkerboard pattern”), white patchy scales (62.5%) and brown reticular lines (50.0%) were the main findings of poikilodermatous MF.
Figure 3.
Folliculotropic mycosis fungoides (a); dermoscopy reveals dilated follicles filled with plugs and devoid of hairs, perifollicular white areas (arrow) and white structureless areas (arrowheads) (b). Erythrodermic mycosis fungoides (c); orange structureless areas along with patchy white scales and dotted (black arrow), linear (white arrow) and linear-curved (arrowhead) vessels arranged in an unspecific pattern are seen on dermoscopic examination (d). Poikilodermatous mycosis fungoides (e); dermoscopy shows focal white and brown structureless areas configuring a “checkerboard” pattern and white patchy scales (f).
Table 2.
Dermoscopic findings of less common forms of mycosis fungoides (MF) with prevalence data (most common features, with a prevalence ≥ 50%, are highlighted in bold).
| Follicular MF (n= 26) (%) | Erythrodermic MF (n=9) (%) | Poikilodermatous MF (n=8) (%) |
|---|---|---|
|
1. Vessels • Dotted vessels (30.8) - Unspecific distribution (19.2) - Peripheral distribution (7.7) - Uniform distribution (3.8) - Clustered distribution (3.8) • Linear curved vessels (15.4) - Unspecific distribution (7.7) - Peripheral distribution (7.7) • Linear vessels with branches (11.5) - Unspecific distribution (7.7) - Peripheral distribution (3.8) 2. Scales • White scales (42.3) - Patchy (34.6) - Diffuse (7.7) • Yellow scales/crusts (7.7) 3. Follicular findings • Follicular plugs (61.5) • Follicular red dots (30.8) • Perifollicular white colour (30.8) 4. Other structures • Focal white structureless areas (11.5) • White circles (7.7) 5. Clues • Dilated follicles (80.8) • Lack of hairs (92.3) |
1. Vessels • Dotted vessels (77.8) - Unspecific distribution (44.4) - Uniform distribution (22.2) - Clustered distribution (11.1) • Linear vessels (77.8) - Reticular distribution (44.4) - Unspecific distribution (33.3) • Linear curved vessels (44.4) - Unspecific distribution (44.4) 2. Scales • White patchy scales (66.7) 3. Follicular findings - 4. Other structures • Focal orange structureless areas (66.7) • Focal brown structureless areas (44.4) • Focal white structureless areas (11.1) • Diffuse orange structureless areas (11.1) • Brown reticular lines (33.3) • White dots (11.1) • Brown dots (11.1) • White globules (11.1) 5. Clues - |
1. Vessels • Dotted vessels (37.5) - Unspecific distribution (25.0) - Uniform distribution (12.5) • Linear vessels (37.5) - Unspecific distribution (25.0) - Reticular distribution (12.5) 2. Scales • White patchy scales (62.5) 3. Follicular findings - 4. Other structures • Focal white structureless areas* (87.5) • Focal brown structureless areas* (50.0) • Focal orange structureless areas (37.5) • Diffuse orange structureless areas (12.5) • Focal purple structureless areas (12.5) • Brown reticular lines (50.0) • White perpendicular lines (12.5) • Purple dots (25.0) • White dots (12.5) • White globules (12.5) 5. Clues - |
Arranged in a checkerboard pattern
With regard to the dermoscopic-pathological correlation analysis, it was performed in three, four and five lesions of patch, plaque and tumoral stage of classic MF, respectively; no data was available for other MF subtypes. The following dermoscopic-pathological correspondences were found (Figures 1b,1c,1e,1f,1h,1i): (I) linear/linear-curved vessels and dilated vascular structures in papillary dermis; (II) linear vessels with branches and dilated arborizing vessels in the dermis; (III) orange structureless areas and either areas of erythrocytes extravasation (hemosiderin deposits) in the dermis (patch and plaque stage) or dense cellular infiltration (tumors); (IV) bright white lines/structureless areas and dermal fibrosis; (V) ulceration and loss of epidermis.
DISCUSSION
Previous studies suggested that dermoscopy facilitates the recognition of classic MF, especially in the patch stage, where the discrimination from clinically similar dermatoses may be particularly troublesome.6,8–11 The main reported dermoscopic features of patch stage MF include orange-yellow structureless areas, spermatozoon-like vessels (combination of dotted and linear-curved vessels) and linear vessels. All these criteria were found to be helpful in the differentiation from dermatitis and psoriasis,6,8–10 while only linear vessels have been related to patch-stage MF when compared to small-plaque parapsoriasis.11
Our study is in line with what described in the literature with regard to linear vessels and orange structureless areas, yet we observed a higher prevalence of white scaling (mainly arranged in a patchy pattern or in the skin furrows) and linear-curved vessels. These minor discrepancies might be attributed to the different dermoscopy setting (as most of our included images were captured with dry polarized dermoscopy that preserves scales visibility) and evaluation methodology, since we used a standardized assessment which does not include metaphoric terms in order to be more reproducible.7
For plaque and tumoral stage of classic MF, there are limited data on their dermoscopic morphology as no studies have been published in this regard.5 Albeit they may share some dermoscopic features with patch-stage MF, we found several significant differences in the comparative analysis. In detail, with disease progression from patches to tumoral lesions there is a change in vascular pattern, with linear vessels predominating at the patch stage and linear vessels with branches at the tumoral stage. On the other hand, plaques do not feature any specific vascular morphology, though there is a lower prevalence of linear-curved vessels corresponding to thin vessels in deep papillary dermis as they are displaced downwards by the dense cellular infiltrate, thus becoming harder to see on dermoscopy. In addition, bright white structureless areas are mainly seen in more advanced phases (plaques and tumoral lesions) and tumors are also characterized by the presence of ulceration and red globules separated by white lines with a lower prevalence of scaling.
Of note, some authors suggested that stage characterization of classic MF should be done through correlation with the histopathological features as clinical differentiation may be challenging and very subjective.4 In this regard, dermoscopy may be of aid for a more precise definition as it may serve as a bridge between clinical and histological assessment.6 Indeed, the aforementioned dermoscopic differences among classic MF stages reflect their different histopathological background, as underlined by our dermoscopic-pathological correlation analysis. In particular, we observed an association between bright white structureless areas and dermal fibrosis, which is more common/marked in plaque and tumoral MF stage,12 as well as a correspondence between linear vessels with branches and ulceration and dilated arborizing dermal vessels and loss of epidermis, respectively, that are known to characterize tumoral lesions.4,12 Although we did not study the histological background of the feature termed “red globules separated by white lines”, it is likely to be related to the presence of multinodular lymphomatous cellular infiltration of the dermis, which is a possible presentation of tumoral MF stage.13 Interestingly, besides staging purposes, the link between dermoscopic and histopathological features might also come in handy to define the best biopsy site, as it may be difficult to choose the appropriate area only on clinical ground.
Concerning MF variants, a significant overlap with patch-stage classic MF was observed in erythrodermic MF, with dotted and linear vessels, patchy white scales and focal orange structureless areas being the most common features. These findings are in line with a previous report and may be of aid in assisting the differential diagnosis with other causes of erythroderma, including psoriasis, characterized by uniform dotted vessels and diffuse white scales, atopic dermatitis, mainly featuring yellow scales/serocrusts and patchy dotted vessels, and pityriasis rubra pilaris, which differ by the presence of islands of non-erythematous (spared) skin displaying reticular vessels.14
In folliculotropic MF, follicular keratotic plugs and perifollicular white colour were previously reported as the most frequent features in a few case reports and small case series (total of 13 cases).5,8,15–19 In our study, although follicular plugs were among the most common features of folliculotropic MF, we found that this variant is mainly characterized by dilated follicles and lack of hairs resulting from the neoplastic T-cell infiltration of hair follicles with its with partial destruction.20 Unlike follicular plugs, the latter dermoscopic findings may facilitate the differentiation from other follicular dermatoses (e.g., follicular psoriasis, keratosis pilaris, pityriasis rubra pilaris, follicular lichen planus, phrynoderma, lichen spinulosus, follicular eczema, and infectious folliculitis) that usually do not display these two features.21,22 Notably, besides follicular plugs, active lesions of discoid lupus erythematosus may also rarely feature dilated follicles/lack of hairs, yet this condition is commonly typified by linear vessels with branches and interfollicular white structureless areas that are less frequently seen in folliculotropic MF.23
Finally, two cases of poikilodermatous MF showing reticular brown areas on a pinkish-white/white background with dotted and glomerular or dotted and hairpin vessels have been reported so far in the literature.24,25 These findings are consistent with our analysis, yet the higher number of cases in this study allowed a better dermoscopic characterization of this MF variant. The main dermoscopic features were focal white and brown structureless areas configuring a “checkerboard” pattern, along with brown reticular lines and patchy white scales, while vascular structures were less common. From a dermoscopic-pathological correlation point of view, pigmentary structures would correspond to basal layer pigmentation, whereas white areas and white scaling are likely to be associated with atrophic epidermis/dermal fibrosis and hyperkeratosis, respectively.4,12 The aforementioned dermoscopic findings may be helpful in differentiating poikilodermatous MF from other common forms of poikiloderma, including poikiloderma of Civatte, typically featuring “spaghetti and meatballs” vascular pattern (combination of dotted/globular vessels and linear irregular vessels) and perifollicular whitish (spared) areas,26 and Riehl’s melanosis, which is characterized by brown pseudonetwork, grey dots/granules and telangiectatic vessels.27
CONCLUSIONS
Our findings underline that dermoscopy may allow a more precise characterization of classic MF thanks to a correspondence with histological features, thereby assisting clinical staging and guiding biopsy from a representative area. Additionally, dermoscopic examination may show clues that may help recognize the main MF variants. Importantly, dermoscopic features have to be considered as an additional piece of the diagnostic puzzle, thus clinical decisions should be based on integrating anamnestic, clinical, and dermoscopic findings, in line with the “2-step” rule (clinical differential diagnosis followed by dermoscopic examination).28 The main limitation of this study includes the retrospective design, which is prone to recall and observation biases, which were addressed by involving evaluators who did not contribute to the sample collection. Moreover, dermoscopic variability according to different anatomical areas was not assessed, no controls were included in the analysis of both classic and less common MF subtypes, and dermoscopic-pathological correlations were evaluated only on a limited sample of classic MF cases, with correlations on MF variants being based on previous studies or common reasoning, thus further controlled studies including dermatoscopic-histological correlations and subanalyses according to lesions localization are needed.
Acknowledgement:
The patients in this manuscript have given written informed consent to the publication of their case details.
The manuscript is an original unpublished work and it is not submitted for publication elsewhere. All writers and contributors who participated in the preparation of the manuscript are listed as authors.
Data Availability Statement:
The data that support the findings of this study are available from the corresponding author upon reasonable request.
There are no financial disclosures and conflicts of interest, except for Shamir Geller and Patricia Myskowski who declare that their research was funded in part through the NIH/NCI Cancer Center Support Grant/Core Grant (P30 CA008748).
References:
- 1).Willemze R, Cerroni L, Kempf W, et al. The 2018 update of the WHOEORTC classification for primary cutaneous lymphomas. Blood 2019; 133:1703–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2).Muñoz-González H, Molina-Ruiz AM, Requena L. Clinicopathologic Variants of Mycosis Fungoides. Actas Dermosifiliogr 2017; 108:192–208. [DOI] [PubMed] [Google Scholar]
- 3).Errichetti E, Chiacchio R, Piccirillo A. Folliculotropic mycosis fungoides presenting as non-inflammatory scarring scalp alopecia associated with comedo-like lesions. Int J Dermatol 2016; 55:e40–1. [DOI] [PubMed] [Google Scholar]
- 4).Cerroni L Mycosis fungoides. In: Skin lymphoma: the illustrated guide (Cerroni L, ed), 5th edn. Hoboken, NJ: John Wiley & Sons, 2020; 23–112. [Google Scholar]
- 5).Sławińska M, Sokołowska-Wojdyło M, Olszewska B, Nowicki RJ, Sobjanek M, Zalaudek I. Dermoscopic and trichoscopic features of primary cutaneous lymphomas - systematic review. J Eur Acad Dermatol Venereol 2021; 35:1470–84. [DOI] [PubMed] [Google Scholar]
- 6).Lallas A, Apalla Z, Lefaki I, et al. Dermoscopy of early stage mycosis fungoides. J Eur Acad Dermatol Venereol 2013; 27:617–21. [DOI] [PubMed] [Google Scholar]
- 7).Errichetti E, Zalaudek I, Kittler H, et al. Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society. Br J Dermatol 2020; 182:454–67. [DOI] [PubMed] [Google Scholar]
- 8).Ghahramani GK, Goetz KE, Liu V. Dermoscopic characterization of cutaneous lymphomas: a pilot survey. Int J Dermatol 2018; 57:339–43. [DOI] [PubMed] [Google Scholar]
- 9).Xu C, Liu J, Wang T, Luo Y, Liu Y. Dermoscopic patterns of early-stage mycosis fungoides in a Chinese population. Clin Exp Dermatol 2019; 44:169–75. [DOI] [PubMed] [Google Scholar]
- 10).Ozturk MK, Zindancı I, Zemheri E. Dermoscopy of stage llA mycosis fungoides. North Clin Istanb 2019; 7:174–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11).Errichetti E, Lallas A, Apalla Z, Stinco G. Dermoscopy of chronic superficial scaly dermatitis (small-plaque parapsoriasis): a controlled comparative morphological study. Int J Dermatol 2021; 60:e94–6. [DOI] [PubMed] [Google Scholar]
- 12).Goodlad J, Calonje E. Cutaneous lymphoproliferative diseases and related disorders. In: McKee’s Pathology of the Skin (Calonje E, Brenn T, Lazar A, McKee PH, eds), 4th edn. Edinburgh: Elsevier Saunders, 2012, 1312–24. [Google Scholar]
- 13).Goyal A, Goyal K, Carter JB, et al. Mycosis fungoides. In: Atlas of Cutaneous Lymphomas: Classification and Differential Diagnosis (Carter JB, Goyal A, McDivitt DuncanL, eds), 1st edn. London: Springer, 2015; 32–41. [Google Scholar]
- 14).Errichetti E, Piccirillo A, Stinco G. Dermoscopy as an auxiliary tool in the differentiation of the main types of erythroderma due to dermatological disorders. Int J Dermatol 2016; 55:e616–8. [DOI] [PubMed] [Google Scholar]
- 15).Jurakic Toncic R, Ledic Drvar D, Bradamante M et al. Early dermoscopic sign of folliculotropism in patients with mycosis fungoides. Dermatol Pract Concept 2018; 8: 328–329. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16).Caccavale S, Vitiello P, Franco R et al. Dermoscopic characterization of folliculotropic mycosis fungoides selectively localized on trunk and limbs. Int J Dermatol 2019; 58: e187–e189. [DOI] [PubMed] [Google Scholar]
- 17).Geller S, Rishpon A, Myskowski PL. Dermoscopy in folliculotropic mycosis fungoides-A possible mimicker of follicle-based inflammatory and infectious disorders. J Am Acad Dermatol 2019; 81: e75–e76. [DOI] [PubMed] [Google Scholar]
- 18).Trueb RM. Systemic Lymphoproliferative Diseases. In: Atlas of Trichoscopy (Rudnicka L, Olszewska M, Rakowska A, eds), 1st edn. London: Springer, 2012; 475–480. [Google Scholar]
- 19).Sławinska M, Sobjanek M, Olszewska B, Nowicki R, Sokołowska-Wojdyło M. Trichoscopic spectrum of folliculotropic mycosis fungoides. J Eur Acad Dermatol Venereol 2018; 32: e107–e108. [DOI] [PubMed] [Google Scholar]
- 20).Errichetti E, Durdu M. Reply: Application of dermoscopy in folliculotropic mycosis fungoides. J Am Acad Dermatol 2019; 81:e77–8. [DOI] [PubMed] [Google Scholar]
- 21).Durdu M, Errichetti E, Eskiocak AH, Ilkit M. High accuracy of recognition of common forms of folliculitis by dermoscopy: An observational study. J Am Acad Dermatol 2019; 81:463–71. [DOI] [PubMed] [Google Scholar]
- 22).Gangadhar M, Adya KA, Inamadar AC. A Study of Clinical, Dermoscopic and Histopathological Correlation in Follicular Keratotic Diseases: Preliminary Observations in 30 Cases. Indian Dermatol Online J 2021; 12:731–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23).Żychowska M, Żychowska M. Dermoscopy of discoid lupus erythematosus - a systematic review of the literature. Int J Dermatol 202; 60:818–28. [DOI] [PubMed] [Google Scholar]
- 24).Xu P, Tan C. Dermoscopy of poikilodermatous mycosis fungoides (MF). J Am Acad Dermatol 2016; 74:e45–7. [DOI] [PubMed] [Google Scholar]
- 25).Nojima K, Namiki T, Miura K, Tanaka M, Yokozeki H. A case of CD8+ and CD56+ cytotoxic variant of poikilodermatous mycosis fungoides: Dermoscopic features of reticular pigmentation and vascular structures. Australas J Dermatol 2018; 59:e236–8. [DOI] [PubMed] [Google Scholar]
- 26).Errichetti E, Stinco G. Dermoscopy in Facilitating the Recognition of Poikiloderma of Civatte. Dermatol Surg 2018; 44:446–7. [DOI] [PubMed] [Google Scholar]
- 27).Wang L, Xu AE. Four views of Riehl’s melanosis: clinical appearance, dermoscopy, confocal microscopy and histopathology. J Eur Acad Dermatol Venereol 2014; 28:1199–206. [DOI] [PubMed] [Google Scholar]
- 28).Errichetti E Dermoscopy of Inflammatory Dermatoses (Inflammoscopy): An Up-to-Date Overview. Dermatol Pract Concept 2019; 9:169–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
There are no financial disclosures and conflicts of interest, except for Shamir Geller and Patricia Myskowski who declare that their research was funded in part through the NIH/NCI Cancer Center Support Grant/Core Grant (P30 CA008748).