DOI: 10.1111/j.1468-3083.2009.03239.

x JEADV

ORIGINAL ARTICLE

Dermoscopy of Kaposis sarcoma: Areas exhibiting the

multicoloured rainbow pattern
S C-S Hu, C-L K Ke, C-H Lee,,, C-S Wu,, G-S Chen,, S-T Cheng,,*

Department of Dermatology, Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Dermatology of Dermatology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Department of Dermatology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan

Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan

*Correspondence: Shih-Tsung Cheng. E-mail: tennsichong@yahoo.com.tw

Abstract
Background Kaposis sarcoma is a vascular tumour characterized by a proliferation of spindle cells and endothelial
cells to form closely arranged slit-like vascular spaces. Currently, the definitive diagnosis of Kaposis sarcoma relies on
histology. The dermoscopic features of Kaposis sarcoma are not clearly defined in the scientific literature.
Objectives We seek to evaluate the dermoscopic features of Kaposis sarcoma and compare them with other vascular
tumours.
Methods One hundred forty-one lesions from seven patients with histologically proven Kaposis sarcoma were
evaluated using polarized light dermoscopy for the presence of various dermoscopic features. Twenty patients with other
vascular tumours were also examined.
Results Dermoscopic examination revealed bluish-reddish coloration (84% of lesions), multicoloured areas showing
various colours of the rainbow spectrum (36%), scaly surface (29%), and small brown globules (15%). The rainbow
pattern was found in six out of seven patients with Kaposis sarcoma and was not observed in other vascular tumours.
In addition, there was an absence of dermoscopic features specific for other vascular and non-vascular skin tumours,
such as well-defined lacunae or structured vascular pattern, in most of the Kaposis sarcoma lesions.
Conclusions The most frequent dermoscopic patterns in Kaposis sarcoma were found to be bluish-reddish coloration,
the rainbow pattern, and scaly surface. The rainbow pattern is a dermoscopic feature which has not been previously
described. We propose that dermoscopy, as an adjunct to clinical examination, may enhance accuracy in the
preoperative diagnosis of Kaposis sarcoma.
Received: 8 June 2008; Accepted 29 January 2009

Keywords
dermoscopy, Kaposis sarcoma, preoperative diagnosis, rainbow pattern, vascular structure, vascular tumour

Conflicts of interest
None declared.

Introduction have recently been characterized, including angiokeratoma,7,8

Kaposis sarcoma is a vascular neoplasm first described by Kaposi
in 1872. It can be divided into four clinical groups: classic,
epidemic [associated with acquired immune deficiency syndrome
(AIDS)], iatrogenic (in patients with immunosuppression), and
endemic (African). Histologically, Kaposis sarcoma is a vascular
tumour characterized by a proliferation of spindle cells and
endothelial cells to form closely arranged slit-like vascular spaces.1
Dermoscopy is a non-invasive method that increases accuracy
in the diagnosis of pigmented as well as non-pigmented skin
lesions.26 The dermoscopic features of various vascular tumours
pyogenic granuloma,9,10 port-wine stain,11 and lymphangioma
circumscriptum.12 To the best of our knowledge, no dermoscopic
criteria have been reported in the medical literature for the
diagnosis of Kaposis sarcoma. In this report, we describe the
dermoscopic features of Kaposis sarcoma in a series of patients
and compare them with other vascular tumours.
Methods
In this study, seven patients with Kaposis sarcoma who presented
to the Dermatology outpatient department of our hospital were

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Dermoscopy of Kaposis sarcoma 1129

examined. All seven patients had histopathologically proven
Kaposis sarcoma. None of the patients had undergone local or
systemic treatment for Kaposis sarcoma at the time of
dermoscopic examination. In addition, we evaluated 20 patients
with nonKaposis sarcoma vascular tumours (including 5 patients
with capillary haemangioma, 4 patients with pyogenic granuloma,
4 patients with cherry haemangioma, 3 patients with angiokeratoma,
2 patients with port-wine stain, and 2 patients with venous lake).
All vascular lesions (including all Kaposis sarcoma lesions in the
seven patients) were examined with polarized light dermoscopy,
using DermLite Foto (3Gen, Dana Point, California) mounted on
a digital camera (Nikon Coolpix 995, Nikon, Japan). DermLite
Foto is a dermoscope with cross-polarization filters, and does not
need immersion fluids. The use of cross-polarization filters
reduce the reflection of light from the surface of the skin, allowing
visualization of deeper structures.13,14 All dermoscopic images
were displayed on a computer screen and were evaluated by three
dermatologists experienced with dermoscopy (S.C.H., C.W., S.C.).
For histologic examination, biopsy specimens of Kaposis
sarcoma lesions were routinely stained with haematoxylin and eosin.
Results
Clinical characteristics of patients with Kaposis sarcoma
Patients 15 were elderly Taiwanese males with classic Kaposis
sarcoma, whereas patients 6 and 7 were young males with AIDS.
One of the patients (patient 1) had more than 100 lesions
distributed on his arms and legs (Table 1).
Features of Kaposis sarcoma lesions under polarized light
dermoscopy
Dermoscopic examination was performed for all Kaposis
sarcoma lesions in the seven different patients (total, 141 lesions).
The most frequent dermoscopic patterns in Kaposis sarcoma
were found to be bluish-reddish coloration (84% of lesions),
multicoloured areas showing various colours of the rainbow
spectrum (36%), scaly surface (29%), and small brown globules
(15%). Dermoscopic examination was performed with two
DermLite Foto dermoscopes with consistent results. The number
of Kaposis sarcoma lesions showing each of the different
dermoscopic features is presented in Table 1.
Most lesions were characterized by bluish-reddish coloration
(Fig. 1a,b), including shades of purple. The colour tone for a
particular Kaposis sarcoma lesion on dermoscopic examination
was sometimes variable, with both darker (red or blue) and paler
(whitish-blue, whitish-red, whitish) areas being present in the
same tumour. In some areas, dermoscopic examination showed
many different colours juxtaposed next to each other (Fig. 2).
Various colours of the rainbow spectrum (ranging from red to
violet) could be seen. We therefore describe these areas as exhibiting
the rainbow pattern. The multicoloured rainbow pattern was
seen in six out of seven patients with Kaposis sarcoma and was
consistently observed using two separate DermLite Foto dermo-
scopes. In some areas, the rainbow pattern involved a large part of
the lesion, while in other areas, this colourful pattern was seen in
only a small part of the lesion. The multicoloured pattern was
observable at low dermoscopic magnification (10) in some
lesions, but in other lesions, it was more readily appreciable at
higher dermoscopic magnification or on enlarged digital pictures.
The optical zoom of the camera allowed enlargement of areas
showing the rainbow effect, but it did not change the colour or
shape of the rainbow pattern. The rainbow pattern was always
present in exactly the same places when patient 1 was examined
on four different occasions over a 3-month period.
In addition, scaly surface was evident in some areas (Fig. 1c).
Small brown globules were also visualized in a few places (Fig. 1d).
In most of the Kaposis sarcoma lesions, there was an absence of
features specific for other vascular and non-vascular skin tumours,
including well-defined lacunae (multiple red, round to oval struc-
tures) or structured vascular pattern (such as dotted vessels, glo-
merular vessels, arborizing vessels, crown vessels, hairpin vessels,
or comma vessels).

Table 1 Dermoscopic features of patients with Kaposis sarcoma

Patient Age/sex Location Number of Number of lesions showing a particular dermoscopic feature
Kaposis Bluish-reddish Rainbow Scaly Small brown
sarcoma lesions coloration pattern surface globules
1 80/Male Legs, arms 114 94 43 36 18
2 74/Male Legs 9 8 2 1 1
3 67/Male Sole 1 1 1 1 0
4 81/Male Foot 3 3 2 1 0
5 67/Male Arms 5 5 1 0 0
6 30/Male Trunk, limbs 6 4 2 2 2
7 29/Male Back 3 3 0 0 0
Overall (%*) 141 118 (84%) 51 (36%) 41 (29%) 21 (15%)
*Percentage of total number of lesions.

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1130
Features of nonKaposis sarcoma vascular tumours under
polarized light dermoscopy
We examined 20 patients with nonKaposis sarcoma vascular
tumours (including capillary haemangioma, pyogenic granuloma,
cherry haemangioma, angiokeratoma, port-wine stain, and venous
lake). Some of the patients presented with multiple lesions
(including those with capillary haemangioma, cherry haemangioma
JEADV 2009, 23, 11281132 Journal compilation 2009 European Academy of Dermatology and Venereology
Hu et al.
Figure 1 Dermoscopic examination
revealed bluish-reddish coloration (a, b),
scaly surface (c; indicated by black arrows)
and small brown globules (d; indicated by
black arrows). DermLite Foto [original
magnification, 10 (a, b, c), 20 (d)].
Figure 2 The rainbow pattern in Kaposis
sarcoma under polarized dermoscopy.
DermLite Foto [original magnification, 10
(a, c)]. Figures (b) and (d) are magnified
views of the black squares in (a) and (c),
respectively.
and angiokeratoma), while others presented with single lesions
(those with pyogenic granuloma and venous lake). Capillary
haemangioma, angiokeratoma, and cherry haemangioma showed
well-defined reddish vascular lacunae on polarized dermoscopy
(Fig. 3a,b). Other dermoscopic features include homogeneous
reddish coloration for pyogenic granuloma, homogeneous
bluish coloration for venous lake, and red globular vessels for
2009 The Authors
Dermoscopy of Kaposis sarcoma
Figure 3 Dermoscopic examination of
cherry haemangioma (a) and
angiokeratoma of Fordyce (b) revealed
lacunae structures. On dermoscopy,
venous lake revealed homogeneous bluish
coloration (c), and port-wine stain showed
red globular vessels (d). There was no
evidence of the rainbow pattern in any of
these vascular tumours. DermLite Foto
(original magnification, 10).
port-wine stain (Fig. 3c,d). In addition, scaly surface was found in
4 out of 20 nonKaposis sarcoma vascular tumours and brown
globules in 3 out of 20 nonKaposis sarcoma vascular lesions. In
none of these nonKaposis sarcoma vascular tumours was a
rainbow pattern seen on polarized light dermoscopy.
Histopathology of Kaposis sarcoma lesions
All seven patients had histopathologically proven Kaposis
sarcoma. In the dermis, there was a proliferation of spindle cells
and endothelial cells. The spindle cells formed slit-like vascular
spaces containing erythrocytes and were organized into closely
packed back-to-back vascular networks in many areas. There
were also extravasated erythrocytes, haemosiderin-containing
macrophages, and hyaline globules. In the epidermis, diminished
rete ridges could be seen.
Discussion
The dermoscopic features of Kaposis sarcoma are poorly
defined in the scientific literature. Previously, Krischer et al. found
that Kaposis sarcoma lacked any specific diagnostic features on
dermoscopy.15,16 In our dermoscopic examination of more than 100
Kaposis sarcoma lesions, most of the tumours were characterized
by bluish-reddish coloration, which reflects the vascular nature of
Kaposis sarcoma. In some Kaposis sarcoma lesions, the colour
tone was variable, with both darker (red or blue) and paler
(whitish-blue, whitish-red, whitish) areas being observed in the
same tumour. The darker areas may correspond to more vascular
regions of the tumour, while the paler areas may correspond to
less vascular regions with relatively greater amounts of spindle
cells and connective tissue. However, further histopathologic
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1131
correlations will be required to confirm this. We were unable to
find any prominent structured vascular pattern on our dermoscopic
examination of Kaposis sarcoma, which is conceivable considering
that histologically Kaposis sarcoma is composed of tiny vascular
spaces which are too small to be visualized on normal dermoscopic
magnification. The scaly surface could partly be a result of eczematous
changes developing in some Kaposis sarcoma lesions.
Most characteristically, we found areas characterized by many
different colours juxtaposed next to each other. Various colours of
the rainbow spectrum could be found. The mechanism underlying
the rainbow effect is not known. We propose that it may be caused
by the optical phenomenon known as diffraction, which describes
the bending of waves around small obstacles and small openings.
Diffraction may cause white light to be split into different
wavelengths (thus producing a rainbow effect) when light passes
through a series of openings or slits that are closely spaced and
parallel to each other. This phenomenon is most prominent when
the repeat distance between the openings is similar to the wave-
length of light.17 Ordinary compact discs, its surface consisting of
closely arranged small pits that are arranged into concentric rings,
are examples of diffraction devices which can generate the rainbow
pattern on its surface.
A characteristic histologic feature of Kaposis sarcoma is that
the vascular lumina are so closely set that they lie next to each
other in a back-to-back arrangement, separated by flattened
endothelial cells. These vessels are arranged mainly parallel to the
epidermis, forming a honeycomb-like pattern of vascular spaces.
The average thickness of an endothelial cell is around 200 nm.18
The visible light corresponds to a wavelength range of 400700 nm.17
Therefore, the closely set honeycomb-like pattern of vascular
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Journal compilation 2009 European Academy of Dermatology and Venereology
1132
spaces in Kaposis sarcoma may mimic a diffraction device with
the separation between the vascular lumina similar to the wave-
length of light. This may explain the production of the rainbow
pattern on dermoscopy. On the contrary, in most haemangiomas
(which do not exhibit the rainbow pattern under dermoscopy),
the endothelial cells of the capillary walls are more prominent and
the vessels are separated further apart by intervening stroma.19
In some of the Kaposis sarcoma patients, we also found areas
showing small brown globules. Due to the immaturity of the
vascular structures, Kaposis sarcoma lesions are typified micro-
scopically by significant amounts of extravasated erythrocytes.
Over time, the erythrocytes may be ingested by surrounding macro-
phages. The small brown globules on dermoscopic examination
may correlate histologically with haemosiderin-containing
macrophages, but further histopathologic correlations will be
necessary for confirmation.
Compared to other vascular tumours, the dermoscopic features
of Kaposis sarcoma were characterized by a more bluish hue
(except for venous lake which also appeared bluish under dermos-
copy), and the coloration was more heterogeneous. Moreover,
examination of Kaposis sarcoma lesions under polarized dermo-
scopy did not reveal well-defined lacunae structures (multiple red,
round to oval structures), which are characteristic of other vascular
tumours such as capillary haemangioma, cherry haemangioma
and angiokeratoma.7 In particular, the rainbow pattern was not
observable on polarized dermoscopy in the nonKaposis sarcoma
vascular tumours that we have examined.
Interestingly, we also found that the rainbow pattern, which
was visualized on polarized dermoscopy (DermLite Foto), could
not be seen using non-polarized dermoscopy (Heine Delta 20; data
not shown). We are currently carrying out ongoing investigations
to compare the dermoscopic features of Kaposis sarcoma when
observed under polarized and non-polarized dermoscopy.
Although more than 100 Kaposis sarcoma lesions were
examined, this study contained limited patient number. In addition,
the observers who performed the dermoscopic examinations were
not blinded to the diagnosis, and the observations were not done
independently by the three observers. Therefore, the reproduc-
ibility of the observations has not been evaluated in this study. In
addition, most of the lesions were contributed by one patient
(patient 1); hence, the frequency of the dermoscopic findings may
be limited in generalizability. Further investigations are warranted
to determine the sensitivity and specificity of the rainbow pattern
as a dermoscopic criterion in differentiating Kaposis sarcoma
from other vascular and non-vascular skin tumours.
In this study, we found that the most frequent dermoscopic
patterns in Kaposis sarcoma were bluish-reddish coloration, the
rainbow pattern, and scaly surface. We have routinely used the
DermLite Foto dermoscope to observe skin tumours (both
pigmented and non-pigmented) and vascular lesions for 3 years
JEADV 2009, 23, 11281132 Journal compilation 2009 European Academy of Dermatology and Venereology
Hu et al.
and have never observed the rainbow pattern previously. In addition,
the rainbow pattern has not been previously described for any
skin lesion in the scientific literature, either with polarized or
non-polarized dermoscopy. Although histopathology remains the
gold standard for diagnosis, we propose that dermoscopy, as an
adjunct to clinical examination, may enhance accuracy in the
preoperative diagnosis of Kaposis sarcoma.
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