INTRODUCTION
There is diverse regional variation in the incidence of pediatric dermatoses. Skin diseases are considered insignificant in many developing countries, even though skin diseases may reflect severe internal dysfunction. Various studies revealed that 30% of total outpatients (outpatient department [OPD]) in the pediatric clinic have a skin ailment, whereas 30% of the dermatology OPD load constitutes the pediatric age group.[1,2] One school-based survey conducted across India reflected an 8.5%–37% prevalence of pediatric dermatosis.[3] Skin diseases in the pediatric age group can be transitory, chronic, or recurrent. Chronic skin conditions have a profound psychological impact and are associated with significant morbidity.
Pediatric dermatoses differ from adult dermatoses regarding varied clinical presentation, treatment, and prognosis. There are certain factors such as socioeconomic status, climatic exposure, external environment, and dietary habits which have a significant influence on childhood dermatosis as compared to adults. School-going children have more prevalence of cutaneous infections. The disorders with intrinsic genetic abnormalities with cutaneous components tend to manifest earlier with onset in the pediatric age group.[4,5,6,7,8,9,10,11] The pattern of skin diseases in India varies significantly across the states, rural and urban areas, and hilly regions. It is observed from various studies that eczematous disorders are more common in developed countries, whereas the prevalence of infectious conditions is more in developing countries.
Using dermoscopy in the pediatric population is advantageous as it avoids emotional stress and physical discomfort. Dermoscopy is better than naked eye examination and improves the clinician's diagnostic accuracy. Dermoscopy is a noninvasive modality that helps in the visualization of subsurface structure which is invisible to bare eyes. There are three ways to perform dermoscopy: nonpolarized dermoscopy, polarized contact dermoscopy, and polarized noncontact dermoscopy. Nonpolarized dermoscopy is a lesion visualization by directly placing the contact plate over the skin with a liquid interface between the skin and the contact plate. Polarized dermoscopy can visualize subsurface structure with or without the contact of skin. Polarized dermoscopy uses cross-polarized filters, which eliminate the reflected light from the skin surface, allowing the reflected light from deeper layers to reach the observer's retina.[12] Polarized noncontact dermoscopy is particularly useful for examining children. The characteristic dermoscopic features help to exclude or diagnose the number of skin disorders in children.[13] This review summarizes such dermoscopic quality of various common pediatric dermatological conditions.
METHODS
The literature was searched systematically using PubMed and Google Scholar databases for English language articles published up to the end of May 2019 using the following keywords: “atopic dermatitis,” “lichen planus,” “psoriasis,” “paediatric dermatoses,” “keratosis pilaris,” “impetigo,” “pityriasis rosea,” “pityriasis Versicolor,” “granuloma annulare,” “vitiligo,” “hypomelanoses of Ito,” “nevus achromicus,” “molluscum contagiosum,” “verrucae,” “lentigines,” “freckles,” “capitis,” “pediculosis,” “alopecia areata,” “linear porokeratosis,” “lichen sclerosis et atrophicus,” “pityriasis alba,” “acanthosis nigricans,” “hand foot mouth,” “seborrheic dermatitis,” “prurigo nodularis,” and “dermoscopy,” “paediatric,” and “dermoscopy” with each condition. Relevant studies were included. Cross-references from each study are also included.
REVIEW RESULTS AND DISCUSSION
Atopic dermatitis
A recurrent itchy flexural rash is characteristic of atopic dermatitis (AD) in children. A dermoscopic pattern could be more specific for AD. Still, the presence of yellow scale-crust and dotted vessels in patchy arrangement over a light red background[14] with an absence of a regular spherical account of the ship will confirm the diagnosis of eczematous etiology and support a diagnosis of AD in an appropriate clinical scenario [Figure 1].
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Figure 1: Yellowish scale crust (red circle), grouped dotted vessel (black circle), typical flexural rash in atopic (inset)
Keratosis pilaris
KP is an autosomal dominant disease characteristic of keratinous plugs in the follicular orifices and varying degrees of perifollicular erythema.[15] Extensor surfaces of the upper arms (92%), thighs (59%), and buttocks (30%) are commonly involved in KP.[16] Dermoscopy of KP papules reveals a coiled or semi-circular intermediate hair embedded superficially in the epidermis with perifollicular erythema and scaling along with follicular keratotic plug [Figure 2]. The hair shaft tends to coil back to its original position after dislodging from the follicular opening with a needle.[17]
Figure 2: Dermoscopy reveals coiled hair with follicular plug (black circle, black arrow), follicular papule over extensor aspect (red circle in inset)
Nevus depigmentosus
Nevus depigmentosus (ND) is commonly present as well as demarcated hypopigmented macule which is widely present at birth with little change after that.[18,19,20] Clinically, ND resembles vitiligo. Dermoscopy of ND illustrates the reticulate pigmented spots within the lesion along with normally pigmented serrated and irregular skin border skin borders and hairs [Figure 3]. In contrast, the lack of a pigment network within the lesion with leukotrichia characterizes vitiligo.
Figure 3: Reticulated pigmented spots (black arrow) over hypopigmented background, hypopigmented macule of ND (inset). ND: Nevus depigmentosus
Impetigo
It is a self-limited condition characterized by honey-colored crust clinically; early diagnosis is critical to avoid complications such as cellulitis (nonbullous form), septic arthritis, osteomyelitis, staphylococcal scalded skin syndrome, septicemia, and acute poststreptococcal glomerulonephritis.[21] Dermoscopy of the lesion reveals a thick honey-colored crust-scale with some irregular vessels at the base as an occasional finding [Figure 4].
Figure 4: Thick honey colored crust-scale (black arrow) with some irregular vessels at base (black circle)
Seborrheic dermatitis
Clinically, this condition is characterized by thick, yellowish, greasy scales adhesive to the scalp, accompanied by intense pruritus. Differentiating scalp psoriasis from isolated seborrheic dermatitis of the scalp may be difficult, due to which the term sebopsoriasis has been coined. Dermoscopy of seborrheic dermatitis reveals arborizing vessels,[22] yellowish scaling, featureless areas, honeycomb pigment, and comma vessels. Other findings such as pigmentations (perifollicular pigmentation and brown dots), other vascular structures, and white/yellow dots constitute less specific findings.[23,24,25,26]
Psoriasis
Psoriasis in children clinically presents as well-defined erythematous plaques covered with silvery scale predominantly involving the extensor surfaces, frequently in a guttate pattern. Dermoscopy of psoriatic plaque reveals regular and symmetric distribution of vessels over erythematous background.[27,28,29,30,31,32,33,34,35,36,37,38,39,40] Dermoscopic “Auspitz sign,” which can be elicited by simply peeling off the scale from the hyperkeratotic plaque, enables the visualization of the abovementioned vascular pattern and possible tiny red blood drops. The other more specific but less frequent vascular pattern “red globular ring” can be visible in plaque psoriasis lesions, while different patterns of vessel distribution are infrequent.[41]
Lichen planus
Lichen planus (LP) is an autoimmune disorder characterized by persistent, polygonal, pruritic, flat-topped, purple to violaceous papules to plaques over any body part.[42] Dermoscopically, it displays Wickham's striae (WS) which are seen as polymorphic pearly whitish structures [Figure 5] with arboriform fern-leaf projections.
Figure 5: Wickham's striae (black arrow) in LP, purple plaque of LP (inset). LP: Lichen planus
WS dermoscopic patterns
There are various patterns of WS described. Reticular pattern is the most common pattern. other pattern such as clustered, starry sky/white dots, follicular white dots, leaf venation are also seen.[43] Crystal structure, radial streaming are more commonly seen in adult rather than in children.
Freckles/ephelides
The ephelide is a sunlight-induced macular lesion over exposed body parts with an average number of melanocytes with increased melanin synthesis. Clinically, they are small macular lesions, usually <3 mm in diameter and brown. Dermoscopy of ephelides generally shows pigmentation in a light-brown, intertwined, tight pigment network and a moth-eaten edge. Uniform areas of pigmentation may also be seen.
Lentigines
Lentigines are commonly seen in light-skinned people and occur due to the proliferation of melanocytes in response to ultraviolet light exposure. Clinically, lentigo appears as dark brown macules over any body part but predominantly affects photo-exposed body parts, including the face. Dermoscopically, it reveals a homogeneous pattern with a delicate, light-brown, typical pseudo network. Sometimes, “moth-eaten edge” is recognized at the lesion's periphery as an uneven concave area resembling the “bite” of a moth over the leaf.[44,45] In this respect, freckles and lentigines share dermoscopic characteristics.
Hand, foot, and mouth disease
Hand, foot, and mouth disease (HFMD) is generally a benign and self-limiting disease. The implicated agents belong to the Picornaviridae family, the most common being coxsackievirus A16 (CVA16) and human enterovirus 71. Lesions are characterized by blisters over the distal extremities, including palms and soles, as well as the mouth, where petechiae may be present as well, in addition to the gluteal regions.[46] Although the diagnosis of HFMD is predominantly clinical, sometimes, difficulty arises in early and atypical lesions where dermoscopy can be handy. A typical feature of HFMD is appearance of a cyst in the blister along with the occasional hemorrhagic crust [Figure 6].
Figure 6: Vesicle in vesicle appearance (black arrow), vesicles over erythematous base (inset)
Molluscum contagiosum
MC is a cutaneous infection by a DNA poxvirus. Typical lesion constitutes an umbilicated white papule few of which are confused with milia, warts, or occasionally pink Spitz nevi. Dermoscopically, MC reveals central umbilication surrounded by peripheral amorphous white to yellow polylobular structure, which corresponds to the hyperplastic squamous epithelium in the dermis. The blood vessels cover the central umbilication in a typical crown pattern. This arrangement is also known as the red corona [Figure 7].[47] The vessels originating from the periphery traverse/radiates toward the center and rarely crossover to the other side. This pattern is produced due to compression and separation of the vessels by collagenous septa.
Figure 7: Whitish yellow amorphous structure (black arrow) with peripheral vessel in crown pattern not crossing midline (yellow arrow), dome-shaped papules over nose (black circle) (inset)
Alopecia areata
AA generally manifests as a circular well-defined area of patchy hair loss affecting the scalp and sometimes other hairy places. The dermoscopy of active lesions reveals a black dot corresponding to fractured hair at scalp level and the presence of “exclamation mark” hairs. Dermoscopic black dots are frequently seen in AA and correspond to fractured or tapered hair shafts. The other feature includes the presence of yellow folliculocentric dots [yellow arrow, [Figure 8]], a commonly seen quality in AA.[48] Dermoscopic credibility can be demonstrated by pressing the dermoscopy against the hair shaft resulting in kinking near the base.
Figure 8: Exclamation mark hair (red arrow), black dots (black arrow), yellow folliculocentric dots (yellow arrow)
Verrucae
Warts occur due to human papillomavirus infection. Few other conditions, such as calluses and corns, mimic warts.[49] Dermoscopy of the wart reveals multiple papillae with central red or black dots [Figure 9] or a loop surrounded by a “whitish halo.” The red dots and loops represent normal vessels, whereas the black dot reveals thrombosed capillaries.[50]
Figure 9: Densely packed papilla with central red dot which corresponds to vessel passing through each papilla
Pityriasis versicolor
Pityriasis versicolor clinically presents as well-defined hyperpigmented/brown/black/red-colored macules over the back or seborrheic distribution. Dermoscopy of hypopigmented lesion reveals fine whitish scales predominantly in skin furrows and perifollicular area.
Pediculosis capitis
Various diseases such as seborrheic dermatitis, AD, tinea capitis, and pediculosis capitis manifest as itchy and scaly scalp lesions. Dermoscopy of these lesions will help in differentiating these causes. Dermoscopy of pediculosis-infested scalp reveals nits (eggs) and live lice.[51] If the nits are within 1–2 mm of the scalp's surface, it suggests active pediculosis infestation. Dermoscopy also helps in treatment monitoring where viable nits which contain nymph are brown in color and elliptical shape [[Figure 10], yellow circle]. In contrast, empty egg cases are translucent and oval in shape and have flattened ends [[Figure 10], white ring], and these are loosely attached to hair shafts. Dead nits may also contain a collapsed nymph, which appears as a focal brown area within the unit, and can have an air pocket, which appears as a translucent area within the egg.[52]
Figure 10: Translucent flattened empty egg cases (white circle), ovoid egg with nymph (yellow circle), live lice in hair (inset)
Tinea capitis
Tinea capitis is one of the common infections of the scalp characterized by patchy areas of scaly hair loss, sometimes with features of kerion or favus. Tinea capitis can be diagnosed by light microscopy of infected hairs, and mycological culture remains the gold standard. Dermoscopy of inches, also known as trichoscopy, may assist in the initial clinical diagnosis. Trichoscopy of tinea capitis reveals features such as comma and corkscrew hairs, Morse code hair, pigtail hairs, black dots, broken hairs, and tufted folliculitis [Figure 11].[53,54,55,56,57] Ectothrix- and endothrix-type fungal invasion displays curved comma hairs and C-shaped hair shafts. They are seen in tinea capitis caused by Microsporum canis and Trichophyton tonsurans. Infection by Trichophyton violaceum, Trichophyton Sudanese, and Microsporum langeroni displays corkscrew-shaped hairs.
Figure 11: Trichoscopy showing broken hair (yellow arrow), tufted hair, and whitish scale
Vitiligo
Vitiligo in children is characterized by well-defined depigmented milky white macules. Segmental vitiligo is a common variant seen in children. Dermoscopy characteristically shows a milky white lesion with a complete absence of pigmentary network (yellow circle), and sometimes, leukotrichia (black arrow) may also be seen [Figure 12].[58,59] Perifollicular repigmentation is a sign of regressing lesion.[60] Other findings include reversed pigmentary network, perilesional hyperpigmentation, reticular pigmentation, and telangiectasias.
Figure 12: Milky white lesion with complete absence of pigmentary network (yellow circle) and sometimes, leukotrichia (black arrow)
Pityriasis alba
This is the endogenous eczema of children presenting as ill-defined scaly erythematous papule to plaque in the initial stages, progressing to postinflammatory hypopigmented macular lesions. Dermoscopy shows fine white scaling with an ill-defined hypopigmented area.
Acanthosis nigricans
Due to lifestyle changes, the prevalence of metabolic syndrome and childhood obesity is showing an increasing trend in recent years. Acanthosis nigricans in children presents as a hyperpigmented velvety textural change of the skin over flexures predominantly. Dermoscopy reveals typical crista and sulcus appearance [Figure 13].[61]
Figure 13: Typical crista (black arrow) and sulci appearance (red arrow), Acanthosis nigricans lesions over the neck (Inset)
Pityriasis rosea
PR presents as sharply defined erythematous round or oval fine scaly plaques distributed over the trunk and proximal extremities, classically described as being distributed in an inverted fir-tree pattern. PR lesions show peripheral whitish scaling (“collarette” sign) and dotted vessels within the lesion. The vessels are located focally and are irregular in distribution; diffuse or localized yellowish-orange structureless areas may also be visible.[62,63]
Hypomelanoses of Ito
Hypomelanoses of Ito present as linear and whorled hypomelanosis in blastoid distribution. A dermoscopy of lesion shows a reticular pattern of normal skin pigmentation interspersed between hypopigmented areas, which also retain faint reticular pigmentation [Figure 14].
Figure 14: Reticular pattern of normal pigmentation of skin interspersed between hypopigmented areas which also retain faint reticular pigmentation, Blaschkoid hypopigmented area in a young child (inset)
Genital lichen sclerosus et atrophicus
Genital lichen sclerosis (LS et A) is characterized by porcelain white atrophic plaque, which subsequently forms “figure-of-8” constriction around the introitus. Dermoscopy of vaginal LS shows very sparse vessels, mainly linear, without a specific arrangement [Figure 15]. The early stage of the disease shows dotted vessels. The distinctive and constant features of LS lesions include patchy, structure-less areas, whitish to white-yellowish to pink-whitish, over a diffuse whitish background. Gray-blue dots, usually with a characteristic peppered arrangement corresponding to dermal melanophages, are also frequently seen. Comedo-like openings and scales may be observed.[64]
Figure 15: Very sparse vessels, mainly linear (yellow arrow), without a specific arrangement, hypopigmented atrophic plaque of LS et A (inset). LS et A: Lichen sclerosus et atrophicus
Linear porokeratosis
This is clinically seen as linear hyperpigmented papules to plaques along the blastoid distribution. Dermoscopy shows a hyperpigmented border (linearly arranged dots and globules cornoid lamella), dark brown flecks, and globules on a brownish background in the center [Figure 16].[65]
Figure 16: Dark brown dots and globules on a brownish background in the center with peripheral cornoid lamellae (black arrow), linear arranged plaque over forearm (inset)
Prurigo nodularis
Morphologically, PN is represented as well defined hyperkeratotic papule to plaque distributed predominantly over extremities with positive Koebner's phenomenon. The white starburst pattern represents the dermoscopic hallmark [Figure 17] which constitutes radially arranged whitish lines surrounding the central structure less area. Sometimes, the main structureless area might have hemorrhagic black spots. Other features such as crust(s), erosion(s), and hyperkeratosis/scales can be seen on dermoscopy.[66]
Figure 17: White starburst pattern with central hemorrhagic spot
Granuloma annulare
GA presents asymptomatic erythematous annular plaques with central clearing, which can mimic a variety of other annular dermatoses. Dermoscopically, the most common finding is the presence of unfocussed vessels with variable morphology (dotted, linear-irregular, and branching) over a more or less transparent pinkish-reddish background. Nonvascular results include whitish or yellowish-orange areas, which correspond to fibrosis and granuloma on histopathology, respectively. However, yellowish-orange areas are generally absent in diffuse interstitial granuloma or if granuloma is seated too deep in the dermis. Other nonspecific features visible on dermoscopy include whitish scaling, rosettes, and crystalline structures.[67]
Clinical significance
Pediatric dermatoses are unique in presentation as they might overlap to some extent. The diagnosis of these conditions is complicated because a biopsy may not always be possible since children are not cooperative, and more importantly, parents are reluctant to subject their children to an invasive procedure. It is in this perspective that dermoscopy assumes greater importance in pediatric dermatology as compared to that in adults. The knowledge of dermoscopic features will enable dermatologists to give apt diagnoses avoiding the need for invasive procedures like biopsy in several situations.
Conflicts of interest
There are no conflicts of interest.
Funding
Nil.
Author contribution
Dr. Chatterjee Manas: He has been involved in the basic design, construction, and writing of the review regarding the conditions to be included and the material required to be incorporated in the study. He has been involved in the decision on available literature to be cited. He has reviewed the entire manuscript for correctness and appropriateness of the clinical and dermoscopic images.
Dr. Rajput Gopalsing R: He has been involved in the drafting of the manuscript as per the guidelines of the first author. He has been involved in the sifting of the clinical and dermoscopy image collection available at the disposal of the first author and forwarding the same to the first author for a decision regarding incorporation in the manuscript. He has collected available literature on the subject and sorted them out in the review for the conclusion of the first author.
Dr. Hemdani Ruchi: she has been involved in contributing images to the review as well as reviewing the manuscript for additions/omissions. She has been involved in capturing the images used in the manuscript as well as in the collation of the clinical and dermoscopy of individual patients. She has contributed to the linking of the clinical and dermoscopy component of the manuscript's text.
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