Received: 12 November 2020 Revised: 26 November 2020 Accepted: 1 December 2020

DOI: 10.1111/dth.14631

SHORT PAPER

Dermoscopic characterization of guttate psoriasis, pityriasis

rosea, and pityriasis lichenoides chronica in dark skin
phototypes: An observational study

Rashmi Jindal | Payal Chauhan | Sheenam Sethi

Department of Dermatology, Venereology and

Leprosy, Himalayan Institute of Medical
Sciences, Swami Rama Himalayan University,
Dehradun, India
Correspondence
Payal Chauhan, Assistant Professor,
Department of Dermatology, Venereology and
Leprosy, Himalayan Institute of Medical
Sciences, Swami Ram Nagar, Doiwala,
Dehradun 248140, India.
Email: chauhanpayal89@gmail.com
Abstract
Dermoscopy as a diagnostic tool is attaining impetus in inflammatory dermatoses
with the cumulative description of characteristic findings in most dermatoses obviat-
ing at times the need of biopsy. In this retrospective observational study, 20 histopa-
thology confirmed cases each of pityriasis rosea (PR), guttate psoriasis (GP), and
pityriasis lichenoides chronica (PLC) seen over a period of 3 years were included.
Dermoscopy images were extracted from photography archives for evaluation and
three lesions from each patient (60 lesions each) were analyzed. Comparison of
dermoscopy characters was done among PR, GP, and PLC in pairs using chi-square
test and a P-value of less than .05 was considered significant. Most common back-
ground color in PR (86.7%) and PLC (96.7%) was yellow to yellow-orange and in GP
was dull red to pink (70%). Vessels were visualized in all lesions of GP and most char-
acteristic pattern was regular (93.3%), dotted vessels (95%). In PR 63.3% lesions had
dotted vessels mostly in a patchy distribution (56.7%). Most prominent scale color in
PR was yellow-white (88.3%) and in GP was white-gray (80%). In PLC varying colors
were seen, most prominent being brown (53.3%). Characteristic findings seen only in
PLC were hypopigmented areas (13.3%), brown dots and globules (53.3%) and
orange-yellow structureless areas (61.7%) GP, PR, and PLC reveal specific
dermoscopic findings that can help in differentiating them. Further, the known
dermoscopic criteria for GP, PR, and PLC also apply for dark skin phototypes.

KEYWORDS

dermoscopy, guttate psoriasis, papulosquamous, pityriasis lichenoides chronica, pityriasis

rosea

1 | I N T RO DU CT I O N
As a diagnostic tool, dermoscopy is attaining momentum with the
increasing description of characteristic findings in most dermatoses. Its
horizon has expanded beyond melanoma diagnosis, with a better under-
standing of its use in inflammoscopy, entomodermoscopy, trichoscopy,
1-4
and onychoscopy. Papulosquamous disorder constitutes a large pro-
portion of routine out-patient cases and can have atypical presentations
making the diagnosis challenging. Dermoscopy being noninvasive is
extremely valuable during select times. Pityriasis rosea (PR), guttate pso-
riasis (GP), and pityriasis lichenoides chronica (PLC) are important differ-
ential diagnoses in the settings of a patient presenting with multiple,
erythematous, scaly papules and plaques over the trunk and extremities
(Figure 1A-C). These patients need histopathological confirmation neces-
sitating the invasive procedure of skin biopsy; that has its complications,
ranging from pigmentary changes to scarring and keloid formation in sus-
ceptible individuals. There is limited literature on the dermoscopic char-
acterization of PR, GP, and PLC in dark phototypes. The present study

Dermatologic Therapy. 2020;e14631. wileyonlinelibrary.com/journal/dth © 2020 Wiley Periodicals LLC. 1 of 6

https://doi.org/10.1111/dth.14631
2 of 6 JINDAL ET AL.

T A B L E 1 Frequency of Fitzpatrick skin phototypes and

dermoscopy findings in pityriasis rosea, guttate psoriasis, and
pityriasis lichenoides chronica

Pityriasis
Pityriasis Guttate lichenoides
rosea psoriasis chronica
number (%) number (%) number (%)
Fitzpatrick skin
phototypes (n = 20)
III 8 10 7
IV 9 6 9
V 3 4 4
Dermoscopy characteristic
(n = 60)
Background color
Dull red/pink 0 (0.0) 42 (70.0) 1 (1.7)
Yellow to yellow-orange 52 (86.7) 1 (1.7) 58 (96.7)
Combination of dull red 8 (13.3) 17 (28.3) 1 (1.7)
and yellow-orange
Vessel type
F I G U R E 1 Erythematous scaly papules and plaques in A, guttate Dotted 31 (51.7) 56 (93.3) 2 (3.3)
psoriasis (GP) B, pityriasis rosea(PR), and C, pityriasis lichenoides
Linear 1 (1.7) 1 (1.7) 4 (6.7)
chronica (PLC)
Linear and dotted 6 (10.0) 3 (5.0) 2 (3.3)
was carried out to describe and compare the dermoscopy findings in Milky red areas 0 (0.0) 0 (0.0) 7 (11.7)
patients with GP, PR, and PLC in Fitzpatrick skin type III, IV, and V. Vessel arrangement
Regular 3 (5.0) 57 (95.0) 0 (0.0)
Patchy 34 (56.7) 3 (5.0) 8 (13.3)
2 | MATERIAL AND METHODS Peripheral 11 (18.3) 1 (1.7) 4 (6.7)
Scale color
In this retrospective, record based observational study, clinically
White-gray 11 (18.3) 53 (88.3) 16 (26.7)
suspected and histopathology confirmed cases of PR, GP, and PLC seen
Yellow-white 48 (80.0) 7 (11.7) 25 (43.4)
over 3 years (July 2017-June 2020) were included. Their clinical and
Brown 0 (0.0) 0 (0.0) 32 (53.3)
dermoscopy images were extracted from the photography archives,
Scale distribution
and further evaluation was done for those with available good quality
Patchy 38 (63.3) 19 (31.7) 31 (57.5)
photographs. A total of 29 patients with PR, 22 with GP, and 20 with
PLC were eligible. As the number of qualifying PLC cases was least Peripheral 26 (43.3) 8 (13.3) 0 (0.0)

(20), to maintain uniformity of sample size among groups, 20 PR and Collarette 18 (30.0) 16 (26.7) 2 (3.3)
GP cases were randomly selected for final analysis. Dermoscopy images Central 2 (3.3) 4 (6.7) 28 (46.9)
were captured with iPhone X (12-megapixel camera; Apple Inc., Cuper- Diffuse 21 (35.0) 41 (68.3) 22 (36.7)
tino, California) attached to Dermlite DL200 hybrid, 10x magnification Other findings
(3Gen, San Juan Capistrano, California). Dermoscopy images of three Hypopigmented areas 0 (0.0) 0 (0.0) 8 (13.3)
individual lesions for each case were selected randomly by one investi- Orange-yellow/brown 0 (0.0) 0 (0.0) 37 (61.7)
gator and evaluated by two other investigators, not aware of the structureless areas
clinico-histopathological diagnosis. In case of discrepancy, a consensus Brown dots and globules 0 (0.0) 0 (0.0) 32 (53.3)
was reached after discussion. Information regarding the skin photo-
type was obtained from the clinical records. For photo-type categoriza-
tion Fitzpatrick skin photo-type classification based on the amount of
skin pigment and tanning ability was used.5 The institutional review 3 | RE SU LT S
board approved the study. Statistical analysis was done using SPSS
software version 23. A comparison of dermoscopy characters was The frequency of dermoscopy findings in PR, GP, and PLC is illus-
made among PR, GP, and PLC in pairs (PR vs GP, PR vs PLC, and GP vs trated in Table 1. The most common background color in PR (86.7%)
PLC). The categorical variables were compared using the chi-square and PLC (96.7%) was yellow-orange and in GP was dull red to pink
test, and a P-value of less than .05 was considered significant. (70%) (Figure 2A-C). Vessels were visualized in all GP lesions, and the
JINDAL ET AL.
F I G U R E 2 Dermoscopy exhibiting A,
pink background color in GP and B,
yellow-orange background in PR and C,
PLC. Regularly distributed dotted vessels
in GP (D, black square), patchy dotted
vessels in PR (E, black circle), and irregular
linear vessels in PLC (F, blue square).
(Dermlite DL 200 hybrid, polarized mode,
X10). GP, guttate psoriasis; PLC, pityriasis
lichenoides chronica; PR, pityriasis rosea
most characteristic pattern was dotted vessels (93.3%) seen in a
regular distribution (95%) (Figure 2D). In PR, 63.3% of lesions had
vessels mostly in a patchy distribution (56.7%) (Figure 2E). In PLC,
only 25% of lesions showed vessels predominantly in a patchy
(13.3%) distribution (Figure 2F). The most prominent scale color in
GP was white-gray (88.3%) (Figure 3A), in PR yellow-white (80.0%)
(Figure 3B) and in PLC brown (53.3%) (Figure 3C). These scales
were patchy in the distribution in PR (63.3%) and PLC (57.5%) and
diffuse in GP (68.3%). A collarette of scales was seen in 30% lesions
of PR (Figure 3D) and 26.7% lesions of GP (Figure 3E). Characteris-
tic findings seen only in PLC were hypo-pigmented areas (13.3%),
brown dots and globules (53.3%) and orange-yellow structureless
areas (61.7%) (Figure 3F).
Comparison of dermoscopy findings between PR and GP
(Table 2) elucidated a statistically significant association of dull red/
pink background color, dotted vessels distributed regularly, and dif-
fuse white-gray scale with GP (P < .001). In comparison, yellow-
orange background color, patchy distribution of vessels, and patchy
and peripheral yellow-white scales were significantly associated with
PR. Among PR and PLC (Table 2) significant differentiating features
were patchy dotted vessels and yellow-white scale in PR and brown
scale in PLC. Guttate psoriasis and PLC had distinct dermoscopy char-
acteristics (Table 2). The background color was dull red/ pink in GP
3 of 6
compared to yellow-orange in PLC (P < .001). Regularly distributed
dotted vessels and diffuse white scale strongly favored GP (P < .001).
4 | DI SCU SSION
Inflammoscopy, as a subdivision of dermoscopy, is being practiced
with growing confidence; however, lacunae remain, especially in dark
phototypes. At times PR, GP, and PLC can be challenging to differenti-
ate clinically, and considering their varied management and prognosis,
it becomes imperative to diagnose them accurately. Histopathological
examination is the current gold standard although it is highly uncom-
fortable for the patient. Dermoscopy can help differentiate these
three dermatoses with fair precision avoiding the need for biopsy.
The background color was dull red/pink in most lesions of GP com-
pared to yellow-orange in PR and PLC. This could help differentiate GP
from PLC and PR however; differentiation between PR and PLC on this
aspect was unreliable. Dull red/pink background color in GP possibly rep-
resents the upper dermal inflammation and dilated capillaries seen histo-
pathologically while in PR and PLC a predominant yellow-orange
background corresponds to dermal inflammation along with upper dermal
edema and hemosiderin deposition. Lallas et al and Bilgic et al in 65% and
73.4% cases have reported yellow background color in PR, respectively.6,7
4 of 6
Color of erythema can vary depending on the skin phototype and
Mohamadi et al reported a dull red background in 50% of their PR patients
with Fitzpatrick skin phototype V and VI.8 In the present study however as
more number of patients of PR belonged to skin type III and IV, the
yellow-orange color perception appeared unimpeded by the skin color.
Vessel type and distribution were able to differentiate PR, GP,
and PLC with good precision. Characteristically dotted vessels in a
regular distribution were elucidated in >90% lesions of GP, while in
PR though the predominant type was dotted vessels, the distribution
was patchy. These patterns have been previously reported in PR and
GP and correspond histologically to dilated and tortuous dermal capil-
1,9,10
laries. A similar dermoscopic pattern of diffuse dotted vessels
was seen in all cases of GP reported by Erichetti et al. PLC, on the
10
contrary, had inconsistent vessels, visible in only 25% lesions.
Errichetti et al in their description of eight PLC cases, reported irregu-
lar, branching vessels, milky red areas, and orange-yellow structureless
areas in 87.5% of patients and focal dotted vessels in 62.5%.10 These
irregular vessels represent dilated superficial capillaries without con-
stant papillomatosis. Absence of vessels in majority of PLC lesions in
our study could be because of the darker skin color. Orange-yellow
structureless areas were seen in 61.7% lesions in the present study
and appear specific for PLC. Histopathologically these correspond to
extravasated red blood cells and their degradation products.
JINDAL ET AL.
F I G U R E 3 Dermoscopy of GP
showing diffuse white scales (A, blue
oval), patchy predominantly peripheral
yellow-white scale in PR (B, blue arrows)
and large central brown scale in PLC (C,
black arrow). Peripheral collarette of
scales in GP (D) and PR (E) and black dots/
globules (blue arrow), hypopigmented
areas (black arrow) and orange-yellow
structureless areas (blue square) in PLC
(F). GP, guttate psoriasis; PLC, pityriasis
lichenoides chronica; PR, pityriasis rosea
Scale color and distribution was quite specific for GP being white-
gray in a diffuse distribution. In the PR yellow-white scale in a patchy,
peripheral distribution was most prominent, while in PLC brown or
yellow-white scale in a patchy, central distribution prevailed. Col-
larette of scales in at least two lesions has long been included as PR's
diagnostic criteria, having 100% sensitivity and 81% specificity.11 A
complete collarette of scale with central clearing was seen in an
almost equal number of GP and PR lesions. It helped differentiate
these two from PLC but not from each other. Lallas et al reported
white scales in 85% of their patients with PR and in 70% of them it
was distributed peripherally.6 Mohamadi et al on the other hand
reported white scale in patchy as well as peripheral distribution in
equal proportion.8 Pattern and color of scale in GP appeared similar to
that seen in classic plaque psoriasis helping in accurate differentiation.
In this study characteristic finding of brown scales, brown dots,
and clods, and hypopigmented areas were seen only in PLC.
Hypopigmented areas were reported in 12.5% lesions by Erichetti
et al and correspond to post-inflammatory hypopigmentation.10
Mohamadi et al also reported brown/gray dots and patches in 63.6%
of PR lesions.8 This could represent focal basal vacuolar damage asso-
ciated with pigment incontinence. Since most of our patients had skin
type III/ IV, probably this finding was masked by the prominent
yellow-orange background and was not appreciated in any lesion.
JINDAL ET AL. 5 of 6

T A B L E 2 Comparison of dermoscopy findings between pityriasis rosea and guttate psoriasis, pityriasis rosea, and pityriasis lichenoides
chronica and guttate psoriasis and pityriasis lichenoides chronica

Pityriasis Pityriasis
Pityriasis Guttate lichenoides Guttate lichenoides
rosea psoriasis Pityriasis rosea chronica psoriasis chronica
Dermoscopy number number number number number number
characters (%) n = 60 (%) n = 60 P-value (%) n = 60 (%) n = 60 P-value (%) n = 60 (%) n = 60 P-value
Background color
Dull red/pink 0 (0) 42 (70) <.001 0 (0) 1 (1.7) .315 42 (70) 1 (1.7) <.001
Yellow-orange 52 (86.7) 1 (1.7) <.001 52 (86.7) 58 (96.7) .048 1 (1.7) 58 (96.7) <.001
Combination of 8 (13.3) 17 (28.3) .068 8 (13.3) 1 (1.7) .015 17 (28.3) 1 (1.7) <.001
dull red and
yellow-orange
Vessel type
Dotted 31 (51.7) 56 (93.3) <.001 31 (51.7) 2 (3.3) <.001 56 (93.3) 2 (3.3) <.001
Linear 1 (1.7) 1 (1.7) 1.000 1 (1.7) 4 (6.7) .171 1 (1.7) 4 (6.7) .171
Linear and dotted 6 (10) 3 (5) .298 6 (10) 2 (3.3) .143 3 (5) 2 (3.3) .648
Vessel arrangement
Regular 3 (5) 57 (95) <.001 3 (5) 0 (0) .079 57 (95) 0 (0) <.001
Patchy 34 (56.7) 3 (5) <.001 34 (56.7) 8 (13.3) <.001 3 (5) 8 (13.3) .224
Peripheral 11 (18.3) 1 (1.7) .002 11 (18.3) 4 (6.7) .053 1 (1.7) 4 (6.7) .171
Scale color
White gray 11 (18.3) 53 (88.3) <.001 11 (18.3) 16 (26.7) .274 53 (88.3) 16 (26.7) <.001
Yellow white 48 (80.0) 7 (11.7) <.001 48 (80.0) 25 (43.4) <.001 7 (11.7) 25 (43.4) <.001
Brown 0 (0.0) 0 (0.0) – 0 (0.0) 32 (53.3) <.001 0 (0.0) 32 (53.3) <.001
Scale distribution
Patchy 38 (63.3) 19 (31.7) .001 38 (63.3) 31 (57.5) .196 19 (31.7) 31 (57.5) .26
Peripheral 26 (43.3) 8 (13.3) <.001 26 (43.3) 0 (0) <.001 8 (13.3) 0 (0) .003
Collarette 18 (30) 16 (26.7) .685 18 (30) 2 (3.3) <.001 16 (26.7) 2 (3.3) <.001
Central 2 (3.3) 4 (6.7) .402 2 (3.3) 28 (46.9) <.001 4 (6.7) 28 (46.9) <.001
Diffuse 21 (35) 41 (68.3) <.001 21 (35) 22 (36.7) .849 41 (68.3) 22 (36.7) .001

TABLE 3 Predominant dermoscopy findings in pityriasis rosea, guttate psoriasis and pityriasis lichenoides chronica

S.No Dermoscopy characteristic Pityriasis rosea Guttate psoriasis Pityriasis lichenoides chronica
1 Background color Yellow-orange Dull red/pink Yellow-orange
2 Vessel type Dotted Dotted Inconsistent (linear/dotted, milky red areas)
3 Vessel distribution Patchy Regular Patchy
4 Scale color Yellow white White gray Brown
5 Scale distribution Patchy and peripheral Diffuse Central
6 Additional findings Orange-yellow structureless areas
Hypo-pigmented areas Brown
dots and globules

To conclude (Table 3), a yellow-orange background, patchy dotted
vessels, and patchy, peripheral yellow-white scale characterizes
PR. GP has a dull red/pink background, regular dotted vessels, and a
diffuse white-gray scale. In PLC, the background color is yellow-
orange, vessels are inconsistent, and when present linear or irregular,
and scale is brown to yellow-white in a central distribution. Thus, GP,
PR, and PLC reveal specific dermoscopic findings that can help in dif-
ferentiating them. Further, the known dermoscopic criteria for GP,
PR, and PLC also apply for dark skin phototypes.
CONFLIC T OF INT ER E ST
The authors declare no potential conflict of interest
6 of 6
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Rashmi Jindal https://orcid.org/0000-0002-0188-6486
Payal Chauhan https://orcid.org/0000-0002-0190-4592
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How to cite this article: Jindal R, Chauhan P, Sethi S.
Dermoscopic characterization of guttate psoriasis, pityriasis
rosea, and pityriasis lichenoides chronica in dark skin
phototypes: An observational study. Dermatologic Therapy.
2020;e14631. https://doi.org/10.1111/dth.14631