European Journal of Cardiovascular Medicine

Papulosquamous disorders are those chronic inflammatory conditions of the skin that are characterized by the presence of papules and scales. These include conditions such as psoriasis, lichen planus, pityriasis rosea, seborrheic dermatitis, and chronic dermatitis. These lesions are usually present with overlapping clinical features, which makes accurate diagnosis difficult in some cases [1]. Many of these lesions have characteristic features associated with them, which are essential for diagnosis; however, atypical presentations are also common, leading to uncertainty and the need for invasive investigations. Therefore, accurate diagnosis is crucial for the application of management protocols and the evaluation of prognosis. The patient outcomes differ significantly in each condition because the response to treatment is different for each condition [2]. Routinely, the diagnosis of papulosquamous disorders of the skin has mainly relied on thorough clinical examination along with histopathological evaluation. Although skin biopsy is the mainstay for confirmation of cases, it may lead to patient anxiety and is also associated with the risk of skin scarring or infections, with the additional burden of the cost of the procedure [3]. Recently, there has been a renewed interest in the development of non-invasive diagnostic methods that can increase the accuracy of diagnosis. Dermascopy is one such procedure. The dermatoscopy or epilumenscence microscopy is now being commonly applied in dermatology practice. Its initial development was the evaluation of pigmented lesions; its use has now been expanded to include inflammatory and infectious dermatoses [4]. Dermoscopy basically allows visualization of subsurface skin structures not visible to the naked eye. Visualization of vascular patterns, pigmentations, scaling, and background coloration is possible with dermatoscopy. These features are often specific to disease patterns, thus enabling clinicians to differentiate between different dermatoses that may clinically appear similar [5].  Dermoscopic patterns can provide invaluable information in papulosquamous disorders, which may act as diagnostic clues. The pattern of regularly arranged dotted vessels and white scaling is a typical feature of psoriasis. The presence of Wickham stria is a typical presentation in lichen planus, which appears as fine white reticular lines under dermoscopy [6]. Similarly, seborrheic dermatitis and pytriasis rosea present different, distinctive patterns, which are crucial for early diagnosis [7]. Although dermoscopy is available with these advantages, it remains underutilized in routine practice, particularly for inflammatory skin disorders, because standardized dermoscopic criteria are still under investigation.

Histopathological correlation remains an important procedure used to confirm dermoscopic results and make a conclusive diagnosis. The knowledge of dermoscopic-histopathological relation not only increases the confidence in the diagnosis, but also increases the ability of the clinician in interpreting the dermoscopic appearances more effectively (8). Systematic assessment and correlation of dermoscopic patterns with histopathological results can play an important role in advancing a reliable diagnostic algorithm of papulosquamous diseases. This study was done to determine dermoscopic patterns of various papulosquamous disorders and correlate them with histopathological findings. This study will also assess the clinical usefulness of dermoscopy to reduce unnecessary biopsies and provide information for accurate diagnosis of papulosquamous conditions of the skin.

This cross-sectional observational clinical study was conducted in the Department of Dermatology, Venereology, and Leprology of a tertiary care teaching hospital. The study was carried out over a period of 12 months after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants before study enrolment after explaining the nature of the study in the vernacular language.

Inclusion Criteria

1.       Patients presenting with clinical features of papulosquamous disorders.

2.       Males and Females

3.       All age groups

4.       Those who gave consent for dermoscopy and biopsy

5.       Voluntary participation

Exclusion Criteria

1.       Patients on topical or systemic steroid therapy

2.       Patients with secondary skin infections

3.       Patients with bleeding disorders or on anticoagulants

4.       Not willing to participate or withdraw from the study.

Based on the inclusion and exclusion criteria, a total of n=65 cases were included in the study, out of which n=5 cases were later voluntarily withdrawn from the study. The results of n=60 cases were included for analysis. All the patients were evaluated by an experienced dermatologist, and a provisional diagnosis of papulosquamous disorder was made.

Clinical Evaluation: was done by obtaining detailed history, age, gender, duration of illness, symptoms, site of involvement, and family history. Dermatological evaluation was done thoroughly to evaluate the morphology, distribution, and extent of the lesion.

Dermoscopic Examination: Dermoscopy was performed with a handheld dermoscope with magnification of 10X. Application of polarized and non-polarized modes was done as appropriate for the case. Representative lesions were examined for background colour, vascular pattern, scaling, pigmentation, and presence of other specific findings (Wickham striae). Dermoscope images were captured using a digital camera for documentation and analysis.

Histopathological Examination: Representative skin biopsies were performed as per standard protocol using 2% lignocaine as a local anesthetic. A punch biopsy of 4 mm was taken from all the cases. The specimen was fixed in 10% formalin and sent for histopathological examination to the department of pathology. Correlation of Dermoscopic and Histopathological Findings was correlated in all cases to determine the diagnostic accuracy. 

Statistical analysis: All the available data were refined, segregated, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 25 in Windows format. The categorical variables were expressed as mean, standard deviation, frequency, and percentages. Categorical variables were calculated by the square test for analysis of differences between the groups. A p-value of less than 0.05 was considered statistically significant.

A total of n=60 cases were analyzed for the results of the study. The age range of the cohort was 15 years to 56 years, and the mean age of the population was 34.55 ± 5.5 years. Most of the cases belonged to the age group 31 – 40 years, with 26.7% of all cases. The distribution of cases based on age is given in Table 1. There was a slight male preponderance with 36/60 (60%) cases, and females were 24/60(40%) cases. The male-to-female ratio was approximately 1.5:1.

The clinical diagnosis of the cohort is presented in Table 2. A critical analysis of the table showed that the most frequently present papulosquamous disorder was psoriasis in 40% of cases, followed by lichen planus and pityriasis rosea in 26.7% and 13.3% respectively. No clear clinical diagnosis was established in 8.3% of cases.  Upper limbs were the most commonly involved site (33.3%), followed by lower limbs (25%) and trunk (23.3%). Scalp involvement was seen in 11.7%, and facial lesions were observed in 6.7% of patients. This distribution reflects the common predilection sites for papulosquamous disorders.

The dermoscopic findings of the cases are given in Table 3. A critical analysis of the patients showed white scaling as the consistent finding in 95.8% of cases. Red background was found in 91.7% of cases. Dotted vessels were noted in 87.5% and a regular vascular pattern was seen in 83.3% of cases. These features were classical dermoscopic features associated with psoriasis.  Similarly, in Pityriasis rosea, peripheral collarette scaling is the common pattern in 87.5% of cases. A yellow background was noted in 75% of cases, and central clearing was found to be present in 62.5% of cases. These features are commonly used for differentiating pityriasis rosea from other papulosquamous disorders.

Histopathological Findings in the cases of the study are given in Table 4. A critical analysis of the table showed that the predominant histopathological findings are in various papulosquamous disorders. Psoriasis was characterized by parakeratosis and acanthosis in all cases. Lichen planus showed basal cell degeneration as the principal feature. Spongiosis was the hallmark of pityriasis rosea, while focal parakeratosis was commonly observed in seborrheic dermatitis. Other disorders exhibited mixed histological patterns. This table reinforces histopathology as the gold standard for definitive diagnosis.

The Correlation between Dermoscopic and Histopathological Diagnosis is presented in Table 5. Critical analysis of the table showed that the highest accuracy was noted in lichen planus (93.8%), followed by psoriasis (91.7%). Pityriasis rosea showed an accuracy of 87.5%, while seborrheic dermatitis had 85.7% concordance. The overall diagnostic accuracy of dermoscopy in this study was 90%, indicating a strong correlation with histopathological findings.

Diagnostic Performance of Dermoscopy in comparison with biopsy as gold standard is given in Table 6. A critical analysis of the table showed dermoscopy examination has a sensitivity of 90% and a specificity of 88%. The positive predictive value was 92.3%, while the negative predictive value was 84.6%. Overall diagnostic accuracy was 90%, suggesting that dermoscopy is a reliable diagnostic tool in the evaluation of papulosquamous disorders.

The current study was done with the aim of determining the utility of dermoscopy as a non-invasive diagnostic aid in papulosquamous dermatoses and compared these results with histopathological analysis, which is still considered the gold standard of diagnosis of papulosquamous lesions of skin. The overall diagnostic accuracy in this study was found to be 90% showing a high level of agreement between the dermoscopic and histopathological characteristics. This favors the use of dermoscopy as a valuable adjunct to clinical examination and, in some instances, possibly as an alternative to biopsy, particularly in resource-constrained settings. This will be helpful in patients who are unwilling to undergo invasive biopsies, possibly because of anxiety and economic reasons. We found that psoriasis was the most common disorder diagnosed in this study, with lichen planus and pityriasis rosea coming in second and third places, respectively. This trend is similar to other hospital-based studies on papulosquamous skin lesions, which have already been published in the past, where they reported psoriasis being a dominant papulosquamous disorder [9]. Male preponderance was observed in the current research, which is consistent with previous research that has indicated the skewed gender distribution, which may be because males generally tend to seek health care earlier than females [10]. White scales, red background, and dotted vessels systematically distributed were the most regular dermoscopic changes that were observed in psoriasis. These observations were very well correlated with the histopathological findings such as hyperkeratosis, dilated capillaries within the dermal papillae, and acanthosis. A similar dermoscopic pattern has been reported by previous studies done on papulosquamous lesions of skin, where a frequent dermoscopic pattern was dotted vessels that were in a regular pattern, and silvery-white scales were regarded as characteristic of psoriasis [11]. The high rate of concordance of psoriasis that was observed in the current research is another confirmation of the diagnostic accuracy of dermoscopy in psoriasis. In lichen planus, Wickham striae were found to be the most significant dermoscopic appearance, which was present in almost all cases. These histopathologically correspond to regions of hypergranulosis, which can explain their typical appearance in dermoscopy. Wickham striae have also been cited in previous literature as one of the most specific and pathognomonic features of lichen planus, and thus dermoscopy is very effective in identifying lichen planus, as opposed to other disorders of papulosquamous nature [12]. Pityriasis rosea had a tendency to show peripheral collarette scaling and a yellowish background. There are histological correlates of this focal parakeratosis and spongiosis. Similar findings have been reported in previous studies done in this field, where they emphasized the role of dermoscopy in identifying pityriasis rosea in its early stages, minimizing errors in diagnosis and unnecessary treatment [13]. The sensitivity and specificity rates in the present research are comparable to those reported in earlier studies, where they found that dermoscopy significantly improved the accuracy of diagnosis and also reduced the rate of biopsy when used appropriately in clinics [14]. We found that a comparatively poorer diagnosis of seborrheic dermatitis and other diseases could be explained by the similarity of dermoscopic features of psoriasis and chronic eczema, thus demonstrating the role of histopathological association in uncertain situations. One of the strengths of the study is the systematic correlation of dermoscopic features with histopathology. However, limitations of this study include a relatively small sample size and the inclusion of a limited number of papulosquamous disorders. To further standardize dermoscopic criteria and confirm these results in various populations, larger multicentric studies are needed. In general, dermoscopy proves to be a useful clinical instrument when it comes to the analysis of papulosquamous diseases. Together with clinical judgment, it helps to increase diagnostic accuracy, minimize the use of invasive biopsy, and help to improve patient care.

Dermoscopy is a useful, non-invasive diagnostic method that can greatly improve the clinical examination of papulosquamous diseases. The high correlation of the dermoscopic patterns and the histopathological results in this study is an indication that it can be relied upon in the daily practice of dermatology. Dermoscopy enhances the precision of diagnosis, early identification of disease characteristic features, and distinguishing among clinically similar conditions. Its application may lead to decreased invasive skin biopsies, greater patient comfort, and greater clinical efficiency. Dermoscopy application for the diagnosis and treatment of papulosquamous skin diseases can lead to improved patient treatment and patient outcomes.

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